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CHAPTER 1

Clinical Chemistry is a interdisciplinary branch between chemistry and medicine and covers a
broad field of analytical techniques to detect and measure chemical parameters in body fluids,
cells, or tissues, such as enzymes, hormones, proteins, drugs, or other naturally occurring
chemicals or those either ingested or used to treat disease.
A pipette, pipet, pipettor or chemical dropper is a laboratory tool commonly used in chemistry,
biology and medicine to transport a measured volume of liquid, often as a media dispenser.
Pipettes come in several designs for various purposes with differing levels of accuracy and
precision, from single piece glass pipettes to more complex adjustable or electronic pipettes.
Many pipette types work by creating a partial vacuum above the liquid-holding chamber and
selectively releasing this vacuum to draw up and dispense liquid. Measurement accuracy varies
greatly depending on the style.
CHAPTER 2
CHAPTER 3
CHAPTER 4
Quality Assurance is a management system designed to achieve an acceptable level of
quality services, prevent poor quality and in laboratories is intended to ensure reliability of
results. It comprehensively includes controlling the quality of procedures at each and every step
including Pre-analytical (specimen collection and transport), Analytical (specimen processing in
the lab) and Post-analytical (reporting and interpretation of results).

Concept of total quality management (TQM) is closely interlinked with good laboratory
practices and goes far beyond the widely practiced conventional Quality Control (QC)
procedures. TQM includes Technical accuracy and precision, equipment and supplies, staff
training and skill, financial management (cost effectiveness), lab safety, communication etc.
Recent pressures on pathology laboratories have meant that laboratories no longer have
the numbers of scientists and pathologists they had in the past. This has resulted in more
questions being asked of the QA staff with a steady increase in the number of scientists
employed to address this demand. Quality improvement in the modern clinical laboratory
environment entails the continuous inspection and refinement of processes to ensure the efficient
delivery of services that meet the needs and expectations of those who use them.
Quality assurance in histopathology and cytopathology is underestimated and it is not
well established in Pakistan but the quality assurance scheme in histopathology and
cytopathology started in late 1970s as slide circulation scheme.
Types of QA system
Internal QA: Internal quality assurance covers all stages of lab procedures right from the
collection of specimen to the issuance of final report. The term is sometimes used synonymously
with quality control (QC)
Quality Control is an operational procedure for the continuous monitoring of tests and
results in order to satisfy given requirements. It includes day-to-day monitoring of
reproducibility or precision and design to detect any serious error.External Quality Assessment:
An independent organization or agency at national or international level monitors the

performance of laboratories by distributing a panel of specimens and evaluating the results with
their own known results. 5
Laboratory Accreditation
A national or international organization of standardization accreditates the laboratory
both in managerial and technical aspects and evaluates that whether it meets the international
standards or not. There are different codes for different aspects of laboratory working. ISO 15189
of the Pakistan national accreditation council (PNAC) provides a framework for the design and
improvement of process-based quality management systems by medical laboratories. It is based
on the new standard is intended to promote a common approach to the quality management of
medical laboratories and to all aspec7ts of its operation, from patient preparation and
identification to the collection and examination of clinical samples.
Elements of QA system
1. Quality manual
The quality manual is the definitive working guide to laboratory function and is issued by
the chief executive or designated quality officer. The size of the quality manual will depend on
the size and complexity of the laboratory concerned and may vary in content from facility to
facility. The manual should be written in plain easy to understand language and contain no jargon
that can confuse staff or an external auditor. The use of flow charts can often be used to
demonstrate practices and procedures in a clear and concise manner.
2. Standard Operating Procedures (SOPs)

Standard operating procedures (SOPs) are an essential part of good laboratory practice.
Using SOPs is the best way to maintain the optimal quality of performance in the laboratory by
providing a stable pattern of function for laboratory staff. By enabling everyone working in the
laboratory to understand the various procedures, SOPs ensure consistent quality of work with
appropriate quality assurance procedures and provide guidance for solving problems when
results fail to meet the expected quality standards.
By definition, an SOP is a written standard procedure that has been approved by the
person in charge. Any subsequent change must be authenticated and authorized so that the
precise procedure used on any day is always documented. SOPs should be prepared for every
analytic test undertaken and for all significant activities relating to the practice of the laboratory
Thus, some are intended primarily for test procedures, whilst other documents should be
prepared for specimen collection, specimen storage, laboratory safety, data processing, record
storage, handling of urgent requests, and even for a telephone-answering policy. SOPs should
accurately reflect good laboratory practice and be sufficiently practical to be useable in a routine
service laboratory.
3. Control of Nonconforming Testing
A nonconformance is any variation from the normal or accepted process, procedure or
protocol. This can cover any abnormalities in test results discovered by way of examination of
quality control material, both internal and external, or by regular audits of laboratory processes
and protocols. In terms of the quality system there can only be a nonconformance if there is a
variation from stated quality system information in the quality manual.

The laboratory should have documented policies and procedures to deal with
nonconformance of test results and all associated practices. The protocols for handling
nonconformance should indicate all staff responsible for identifying and evaluating the
significance of the episode and dealing with the situation.
4. Corrective Action
The laboratory should have documented policies and procedures to implement corrective
actions when nonconformance is detected. Corrective actions are not only associated with
failures in the quality of test results, but may also be required when problems in the quality
system are identified following reviews, audits, complaints or other events affecting laboratory
function are observed or recorded. 8
Immediate corrective action may be necessary in order to rectify situations with
immediate impact upon patient care and treatment. These types of incidents also require a
process or procedure, which details personnel authorized to take immediate corrective action and
the mechanism for recording the incident.
5. Record:The laboratory should maintain a comprehensive record keeping system. Records should
include written or electronic material relating to test outputs of the laboratory. The material must
be accessible and stored in a suitable environment. Both quality and technical records should be
kept in accordance with required standards.
Records may include Request for tests, patients result, Workbooks and instrument
printouts, Calibrations and calculations, Critical reagent details such as kit numbers, batch

numbers, expiry dates, date received, Quality control records, external proficiency programs
record, review of records (QC/QA) and proof of scrutiny by authorized, personnel, equipment
maintenance records, complaints and corrective actions, audit reports, both internal and external,
incident or accident records.
Modes of Internal Quality Control
Three modes include:
i. Using Control Material (Commercial or locally pared)
ii. Random Duplicate Sampling
iii. Retesting of randomly selected samples from a evious
day's run
1. Using Control Material (Commercial or locally epared)
QC material usually consists of a serum pool either prepared locally or as more often the
case, purchased commercially. The target values of the QC serum pool are the estimated
concentrations of each analyte within the pool. The manufacturers for their products usually give
mean values along with the estimated higher and lower limits. However, each laboratory must
establish its own values for each analyte under its own laboratory conditions, by the procedures
and the instruments routinely being used by that laboratory.
The target average plus and minus 2SDs is the control limit for each pool sample. These
are also the 95% confidence limits based on parametric statistics

Frequency of QC analysis varies according to different lab protocols. QC analysis may be


run the first thing in the morning before starting regular routine analysis. If values are found to
be within limits the entire day's results are taken as valid. Those labs that work in shifts, QC may
be run at the start of each shift. More common practice, especially where large multi channel
analysers are used, is to include controls after every 20 samples.
When the control values are within the acceptable range then these values should be
recorded in the proper log sheet. Plot the control values in Quality Control Chart i.e. Levey
Jennings quality control charts and interpretation is done according to Westgard Multirules.
2. Random Duplicate Sampling
It is a measure of reproducibility of results and is a useful indicator of accuracy. After
every 5 - 10 samples, a randomly selected duplicate aliquot of any of the samples being tested is
included and the two results are compared. The percentage variation is calculated. A record of
daily readings is kept and cumulative reproducibility observed.

3. Repeat Testing of Previous Day's Samples

It is a measure of reproducibility of results of the same sample tested under the same
experimental conditions on two different occasions. The percentage variations are calculated and
a record maintained.
CHAPTER 5

CHAPTER6
A spectrophotometer consists of two instruments, namely a spectrometer for producing light of
any selected color (wavelength), and a photometer for measuring the intensity of light. The
instruments are arranged so that liquid in a cuvette can be placed between the spectrometer beam
and the photometer. The amount of light passing through the tube is measured by the photometer.
The photometer delivers a voltage signal to a display device, normally a galvanometer. The
signal changes as the amount of light absorbed by the liquid changes.
If development of color is linked to the concentration of a substance in solution then that
concentration can be measured by determining the extent of absorption of light at the appropriate
wavelength. For example hemoglobin appears red because the hemoglobin absorbs blue and
green light rays much more effectively than red. The degree of absorbance of blue or green light
is proportional to the concentration of hemoglobin.
When monochromatic light (light of a specific wavelength) passes through a solution there is
usually a quantitative relationship (Beer's law) between the solute concentration and the intensity
of the transmitted light, that is,

where I sub 0 is the intensity of transmitted light using the pure solvent, I is the intensity of the
transmitted light when the colored compound is added, c is concentration of the colored
compound, l is the distance the light passes through the solution, and k is a constant. If the light
path l is a constant, as is the case with a spectrophotometer, Beer's law may be written,

where k is a new constant and T is the transmittance of the solution. There is a logarithmic
relationship between transmittance and the concentration of the colored compound. Thus,

The O.D. is directly proportional to the concentration of the colored compound. Most
spectrophotometers have a scale that reads both in O.D. (absorbance) units, which is a
logarithmic scale, and in % transmittance, which is an arithmetic scale. As suggested by the
above relationships, the absorbance scale is the most useful for colorimetric assays.
Using a Spectronic 20 spectrophotometer
The Spectronic 20 spectrometer is widely used in teaching laboratories. The specific instructions
will differ with other models, but the principles remain.
1. The instrument must have been warm for at least 15 min. prior to use. The power switch
doubles as the zeroing control.
2. Use the wavelength knob to set the desired wavelength. Extreme wavelengths, in the
ultraviolet or infrared ranges, require special filters, light sources, and/or sample holders
(cuvettes).
3. With the sample cover closed, use the zero control to adjust the meter needle to "0" on the
% transmittance scale (with no sample in the instrument the light path is blocked, so the
photometer reads no light at all).

4. Wipe the tube containing the reference solution with a lab wipe and place it into the
sample holder. Close the cover and use the light control knob to set the meter needle to
"0" on the absorbance scale.
5. Remove the reference tube, wipe off the first sample or standard tube, insert it and close
the cover. Read and record the absorbance, not the transmittance.
6. Remove the sample tube, readjust the zero, and recalibrate if necessary before checking
the next sample.
Why use a reference solution? Can't you just use a water blank? A proper reference solution
contains color reagent plus sample buffer. The difference between the reference and a sample is
that the concentration of the assayable substance in the reference solution is zero. The reference
tube transmits as much light as is possible with the assay solution you are using. A sample tube
with any concentration of the assayable substance absorbs more light than the reference,
transmitting less light to the photometer. In order to obtain the best readability and accuracy, the
scale is set to read zero absorbance (100% transmission) with the reference in place. Now you
can use the full scale of the spectrophotometer. If you use a water blank as a reference, you might
find that the assay solution alone absorbs so much light relative to distilled water that the usable
scale is compressed, and the accuracy is very poor.

CHAPTER7
What is an Immunoassay or ELISA?

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Immunoassays are quick and accurate tests that can be used on-site and in the laboratory to
detect specific molecules. Immunoassays rely on the inherent ability of an antibody to bind to the
specific structure of a molecule. Antibodies are proteins generated by animals in response to the
invasion of a foreign molecule (antigen) into the body. Antibodies are found in blood and tissue
fluids and will bind to the antigen whenever it is encountered. Because antibodies are developed
to the specific three-dimensional structure of an antigen, or analyte, they are highly specific and
will bind only to that structure. Once purified from the blood, monoclonal and polyclonal
antibodies are ideal assay reagents to detect and monitor specific target molecules with limited
interferences from other substances. Four typical ELISA formats are: monoclonal-polyclonal
sandwich assays, competitive inhibition assays, antigen-down immunoassays, and rapid assays.
Monoclonal-Polyclonal Sandwich Immunoassay
In a typical microtiter plate sandwich immunoassay, a monoclonal antibody is adsorbed onto a
plastic microtiter plate. Build an Antibody Sandwich ELISA with Immunochemistry
Technologies' ELISA Solutions When the test sample is added to the plate, the antibody on the
plate will bind the target antigen from the sample, and retain it in the plate. When a polyclonal
antibody is added in the next step, it also binds to the target antigen (already bound to the
monoclonal antibody on the plate), thereby forming an antigen sandwich between the two
different antibodies.
This binding reaction can then be measured by radio-isotopes, as in a radio-immunoassay format
(RIA), or by enzymes, as in a enzyme immunoassay format (EIA or ELISA) attached to the
polyclonal antibody. The radio-isotope or enzyme generates a color signal proportional to the
amount of target antigen present in the original sample added to the plate. Depending on the

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immunoassay format, the degree of color can be detected and measured with the naked eye (as
with a home pregnancy test), a scintillation counter (for an RIA), or with a spectrophotometric
plate reader (for an EIA) (for a price quote, see Sandwich ELISA Development Sample
Proposals).
Step 1: Monoclonal antibodies adsorbed onto the well of a plastic microtiter plate with coating
buffer (no sample added).
Step 2: Addition of a sample (such as human blood, diluted appropriately) to the well of the
microtiter plate. The target antigen binds to the antibody adsorbed on the plate, retaining the
antigen in the well.
Step 3: Binding of an enzyme-conjugated polyclonal antibody to the target antigen (bound to the
monoclonal antibody on the plate), thereby forming an antigen sandwich between the two
different antibodies.
Step 4: Addition of a colorimetric substrate for detection of the enzyme-conjugated polyclonal
antibodies will generate a color signal proportional to the amount of target antigen present in the
original sample added to the plate.
Antigen-Down Immunoassay
In an antigen-down immunoassay, the analyte is coated onto a 96-well microtiter plate (rather
than an antibody) and used to bind antibodies found in a sample. When the sample is added (such
as human serum), the antigen on the plate is bound by antibodies (IgE for example) from the
sample, which are then retained in the well. A species-specific antibody (anti-human IgE for
example) labeled with HRP is added next, which, binds to the antibody bound to the antigen on

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the plate. The higher the signal, the more antibodies there are in the sample. Antigen-down
assays can be configured as rapid tests and are often used to diagnose allergy conditions routinely a patient's blood is tested against different allergens to see if the person has antibodies
to that allergen (for a price quote, see Antigen-Down ELISA Development Sample Proposal).
Competitive Inhibition Immunoassay
In addition to the Monoclonal-Polyclonal (Mo-Po) Antibody Sandwich format, many
immunoassays are structured in a competitive inhibition format. Competitive inhibition assays
are often used to measure small analytes because competitive inhibition assays only require the
binding of one antibody rather than two, as in standard ELISA formats. Because of the high
probability for steric hindrance occurring when two antibodies attempt to bind to a small
molecule at the same time, a sandwich assay format may not be feasible. Therefore a competitive
inhibition assay would be preferable.
In a sequential competitive inhibition assay, the sample and conjugated analyte are added in steps
like a sandwich assay, while in a classic competitive inhibition assay, these reagents are
incubated together at the same time. In a sequential competitive inhibition assay format, a
monoclonal antibody is coated onto a 96-well microtiter plate. When the sample is added, the
MoAb captures free analyte out of the sample. In the next step, a known amount of analyte
labeled with either biotin or HRP is added. The labeled analyte will then also attempt to bind to
the MoAb adsorbed onto the plate, however, the labeled analyte is inhibited from binding to the
MoAb by the presence of previously bound analyte from the sample. This means that the labeled
analyte will not be bound by the monoclonal on the plate if the monoclonal has already bound
unlabeled analyte from the sample. The amount of unlabeled analyte in the sample is inversely

13

proportional to the signal generated by the labeled analyte. The lower the signal, the more
unlabeled analyte there is in the sample. A standard curve can be constructed using serial
dilutions of an unlabeled analyte standard. Subsequent sample values can then be read off the
standard curve as is done in the sandwich ELISA formats. The classic competitive inhibition
assay format requires the simultaneous addition of labeled (conjugated analyte) and unlabeled
analyte (from the sample). Both labeled and unlabeled analyte then compete simultaneously for
the binding site on the monoclonal capture antibody on the plate. Like the sequential competitive
inhibition format, the colored signal is inversely proportional to the concentration of unlabeled
target analyte in the sample. Detection of labeled analyte may be made by using a peroxidase
substrate such as TMB, which can be read on a microtiter plate reader (for price quotes, see
Competitive Inhibition ELISA Sample Proposal).
Rapid Immunoassay
In addition to microtiter plates, immunoassays are also configured as rapid tests, such as a home
pregnancy test. Like microtiter plate assays, rapid tests use antibodies to react with antigens and
can be developed as MoAb-PoAb sandwich formats, competitive inhibition formats, and antigendown formats. With a rapid test, the antibody and antigen reagents are bound to porous
membranes, which react with positive samples while channeling excess fluids to a non-reactive
part of the membrane. Rapid immunoassays commonly come in 2 configurations: a lateral flow
test where the sample is simply placed in a well and the results are read immediately; and a flow
through system, which requires placing the sample in a well, washing the well, and then finally
adding an analyte-colloidal gold conjugate and the result is read after a few minutes. One sample
is tested per strip or cassette. Because rapid tests are faster than microtiter plate assays, require
little sample processing, are often cheaper, and generate yes/no answers without using an
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instrument, they often used in the field by non-laboratory people testing whole samples.
However, rapid immunoassays are not as sensitive nor can they be used to accurately quantitate
an analyte. (Self-monitoring of blood glucose levels by diabetics is considered quantitative rapid
testing, however, immunoassay technology is not used for these tests.) All rapid immunoassay
tests can be converted to a microtiter plate assay, but not all microtiter plate assays can be
converted to a rapid test (for price quotes
CHAPTER8
Clinical laboratory automation technology derives its usefulness from functionality, where
functionality is defined as functions performed or supported by the technology. Functionality
in this case is heavily dependent on the approach that is applied to develop automation
technology. There are several automation design issues that we feel are of importance, including
the philosophy of automation systems design, the implementation of process control software,
the relationship between hardware and software function, user interfaces to the system, the
interface with the laboratory information system (LIS), and the interface between laboratory
automation system (LAS) and other hardware components.
The philosophy of automation system design rests with the inherent understanding of the
designer. Implementation of strictly mechanical concepts into the clinical laboratory may
override the overall mission of the clinical laboratory and its integral involvement in the delivery
of patient care. To develop a philosophy, we believe that the following should be
understood: (a) how the laboratory relates to healthcare; (b) the process of the clinical laboratory;
and (c) the business of the clinical laboratory. From a structural standpoint, either software or
hardware can be made the primary focus of an automation system. As with the early

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development of information technology and other similar advances, hardware technology has
had a prominent place in early automation systems designs. It is our contention that the design of
a LAS should be centered on the patient, with a software design that allows patient-related
information and laboratory process to be under the control (direction) of the software. The
hardware then serves the function of appendages or end-actuators similar to the application of
technology in a parallel environment: computer-integrated manufacturing.
Process control software requires several important components and functionalities, including
the following: (a) a basis in modern information technology, which requires hardware and
operating systems that are vertically upgradable; (b) transportation system management at both
the local (device) and overall system levels; (c) specimen container tracking so that any
specimen can be identified in its physical location on or in the automation system; (d) repeat
testing so that a specimen that may yield a certain result can be rerouted using the rules
embedded in the software to repeat the test on another instrument using a different methodology
or to confirm the test on the same or another instrument; (e) reflex testing where an additional
test can be performed at the same workcell/instrument or a specimen can be trafficked onto
another workcell/instrument for subsequent testing that is the result of applying a rule against the
result of the first test; and (f) information systems integration so that LISs and other information
components of IVD equipment (analyzers) can be combined to make a functional automated
laboratory where the instrument can be managed using rules and other software-driven
parameters to replace the technologist at the individual instrument. For example, the system
software would know through the information passed by the hospital or LIS that the patient
with a high urea value is from the dialysis unit and that the test does not need to be repeated. A
rule can provide the functionality necessary to make the determination.

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There are several important dependencies between software and hardware. If the software
functionality is absent, the hardware cannot be expected to perform. Similarly, if the hardware
functionality is absent, the software cannot be expected to actuate that hardware function; hence,
the hardware and the software functionality are interdependent. It has become clear that to allow
random access, one must have a single tube per carrier design so that each specimen has
individual real-time access to any workcell or device in the LAS. To allow reflex testing, there
must be real-time control of hardware devices and instruments by the software that manages the
overall operation; to allow routing, there must be more than one transportation path to move a
specimen to one or many instruments.
Several software systems now include functionality for both the procedure and the process. At
the procedural level, rules can be applied that allow only the performance of specific tests on an
identified matrix, e.g., only perform sodium on serum or plasma, only perform a complete blood
count on EDTA-treated or heparinized whole blood. The rules processing in the software
component of an automation system should provide the following functionality:(a) the ability to
monitor quality using the process control system; (b) the ability to monitor results; (c) the ability
to monitor the instrument and its operation; (d) the ability to implement repeat testing
decisions; (e) the ability to implement a reflex testing decision; (f)the ability to cancel tests;
and (g) the ability to manage the workload of the entire laboratory operation based on the need
for turnaround time (TAT), throughput, instrument utilization, and instrument uptime.
The ability to interface between the LIS and LASs has been enhanced by the implementation of
Health Level 7 system-to-system interfaces. The NCCLS has issued a proposed standard (AUTO
3P) that specifies the Health Level 7 interface as the system-to-system communications
methodology for connecting a LIS and a LAS.
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The management of the instruments in a clinical LAS environment requires the implementation
of an instrument control software module with instrument-specific rules. In concept, this module
is simply replacing the intelligent operator with embedded rules in the current nonautomated
environment (the medical technologist) with an automation control system with embedded rules
that will allow a predefined level of uninterrupted or controlled operation before human
intervention.
CHAPTER9
CHAPTER10
CHAPTER11
CHAPTER12
Proteins (/protinz/ or /proti.nz/) are large biological molecules, or macromolecules,
consisting of one or more long chains of amino acid residues. Proteins perform a vast array of
functions within living organisms, including catalyzing metabolic reactions, replicating DNA,
responding to stimuli, and transporting molecules from one location to another. Proteins differ
from one another primarily in their sequence of amino acids, which is dictated by the nucleotide
sequence of their genes, and which usually results in folding of the protein into a specific threedimensional structure that determines its activity.
A linear chain of amino acid residues is called a polypeptide. A protein contains at least one long
polypeptide. Short polypeptides, containing less than about 20-30 residues, are rarely considered
to be proteins and are commonly called peptides, or sometimes oligopeptides. The individual
amino acid residues are bonded together by peptide bonds and adjacent amino acid residues. The

18

sequence of amino acid residues in a protein is defined by the sequence of a gene, which is
encoded in the genetic code. In general, the genetic code specifies 20 standard amino acids;
however, in certain organisms the genetic code can include selenocysteine andin certain
archaeapyrrolysine. Shortly after or even during synthesis, the residues in a protein are often
chemically modified by posttranslational modification, which alters the physical and chemical
properties, folding, stability, activity, and ultimately, the function of the proteins. Sometimes
proteins have non-peptide groups attached, which can be called prosthetic groups or cofactors.
Proteins can also work together to achieve a particular function, and they often associate to form
stable protein complexes.
Once formed, proteins only exist for a certain period of time and are then degraded and recycled
by the cell's machinery through the process of protein turnover. A protein's lifespan is measured
in terms of its half-life and covers a wide range. They can exist for minutes or years with an
average lifespan of 12 days in mammalian cells. Abnormal and or misfolded proteins are
degraded more rapidly either due to being targeted for destruction or due to being unstable.
Like other biological macromolecules such as polysaccharides and nucleic acids, proteins are
essential parts of organisms and participate in virtually every process within cells. Many proteins
are enzymes that catalyze biochemical reactions and are vital to metabolism. Proteins also have
structural or mechanical functions, such as actin and myosin in muscle and the proteins in the
cytoskeleton, which form a system of scaffolding that maintains cell shape. Other proteins are
important in cell signaling, immune responses, cell adhesion, and the cell cycle. Proteins are also
necessary in animals' diets, since animals cannot synthesize all the amino acids they need and
must obtain essential amino acids from food. Through the process of digestion, animals break
down ingested protein into free amino acids that are then used in metabolism.
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Proteins may be purified from other cellular components using a variety of techniques such as
ultracentrifugation, precipitation, electrophoresis, and chromatography; the advent of genetic
engineering has made possible a number of methods to facilitate purification. Methods
commonly used to study protein structure and function include immunohistochemistry, sitedirected mutagenesis, X-ray crystallography, nuclear magnetic resonance and mass spectrometry.
CHAPTER13
The field of inherited disorders of the nervous system has undergone major revolutions in the
past 150 years. The 19th century saw the first systemic approach to disease through the use of
rational, consistent outlines for taking histories and doing physical examinations. Scientific
methods were applied to pathology and clinical medicine because of discoveries in physics and
chemistry (both organic and inorganic). The discoveries led to knowledge of the organic
chemistry of dyes, tissue staining, and improved microscopy. The blood pressure apparatus,
thermometer, stethoscope, tuning fork, and later, the reflex hammer were added to the clinician's
armamentarium.[3] With these tools, physicians and pathologists (often the same person) were
able to apply Sir Francis Bacon's dictum to medicine: "inquire carefully into the origin of
things."
Garrod summarized the initial discoveries of the 19th century and the turn of the 20th in his
book, Inborn Errors of Metabolism, some 80 years ago. By the mid 1960s, defects that led to the
accumulation of metabolic products in the urine, blood, or neural tissues were identified. These
defects were largely problems in the catabolism of lipids and amino acids or in the rapid
breakdown of glycogen. The identification of the metabolites that accumulated in a disease made
possible the identification of the enzyme whose activity was deficient.

20

Although direct identification of abnormal protein structure still was not possible, such defects
could be inferred, indirectly, by demonstrating alterations in the kinetic properties of patients'
enzymes (ie, rates of reaction as concentrations of cofactor or substrate were varied) or in the
rate at which heating the enzyme altered its catalytic properties. Such changes allowed a strong
inference of a change in the structure of the enzyme-protein. A change in structure was in those
days thought to be due to a change in an amino acid somewhere in the peptide chain of the
protein. In the case of some hemoglobin variants, demonstrating substitutions of one or another
amino acid was actually possible.

Over the next 2 or 3 decades, errors in glycolysis, the Krebs cycle, and adjacent pathways were
elucidated by such methods, although some of these errors are debated still. By the mid 1980s,
techniques largely had switched from those of the biochemistry of intermediates and enzymes to
the identification of mutations in genes. This was done by a large number of techniques that
make use of DNA fragments (restriction fragment-length polymorphisms) so as to permit linkage
mapping and gene sequencing. As a result, we now know many genetic defects responsible for
neurological disease, but frequently we do not know much about the resulting protein product
and therefore the pathophysiologic basis for the disease.
Pathophysiology
The human genome at one time was estimated to have 70,000-100,000 genes. New data from the
Human Genome Project suggest this number may be closer to 30,000. Many of these appear to
code for proteins produced in the brain. Data from the Human Genome Project surely will be
useful in identifying mutations in the thousands of genes that must underlie inherited diseases of
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the central and peripheral nervous system. Genetic data also will be useful in identifying
mutations and polymorphisms that predispose to some of the acquired diseases of the nervous
system, some of which are discussed in this article. One of the major principles of
pathophysiology that has appeared in recent decades is that many acquired diseases have one or
several genetic bases (predispositions). Another principle is that diseases often appear only after
2 or 3 things go wrong. Some examples of each are discussed in this article.
Until the genes and their mutations that underlie neurological disease are characterized, inherited
disorders have to be defined the way clinicians have been classifying disease over the last 2
centuries. These classifications make use of clinical descriptions in the living patient correlated
with pathologic changes found at autopsy; with chemical changes in excreta, blood,
cerebrospinal fluid (CSF), and tissues, or sometimes with abnormalities found on images of the
brain and other organs. The methods of genetic analysis first described by Mendel and the
correlations with human disease first collected by Garrod were fundamental to the knowledge of
inherited diseases that was acquired in the latter two thirds of the 20th century.
Until the end of the 1970s, only a few methods were available for investigating inherited disease.
They included the following:
Identifying the patterns of inheritance of a syndrome in families as well as unique populations
Correlating syndromes with pathologic or chemical changes in tissues and fluids
Correlating syndromes with increased or decreased concentrations of proteins or alterations in
enzyme activity in the body

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At that time, however, correlating disease states with amino acid substitutions in specific proteins
or peptides was not possible, except for hemoglobin variants: these were well characterized.
Diseases are intellectual constructs, not reality. They are constructs whose definition can change
depending on the speaker, the audience, and most importantly the historical era in which the
disease is described. Names of diseases are useful ways to tie what is being said to the medical
technology and assumptions of the era in which the statement about an illness is being made.
However, the description and definition of a disease each can change as technology improves
and understanding of the pathophysiological processes evolves.
Even the basic name of a disease can change as decades (and even centuries) pass. This is
particularly true in the last century or two. What was called idiocy in the mid-nineteenth century
became subdivided into terms such as amaurotic idiocy, which was later named the following:
Tay Sachs' disease, Tay-Sachs disease, generalized gangliosidosis, generalized GM2
gangliosidosis, infantile type with McKusick classification 230500. The current disease name is
severe deficiency of hexosaminidase A with infantile onset of symptoms.
The reality of medicine is the sick patient. The definition of a specific disease has less correlation
to the real world than the construct of species has in biology. This is true even for genetic
diseases, although genetic diseases superficially appear to be linked closely to a specific cause, a
specific mutation. That this is not always true is discussed later in the article, under
Polymorphism With and Without Disease.
Another critical issue in the definition of disease is that having a genetic defect that may result in
a disease is not the same as having the disease. Having the defect means only having a
propensity or a risk of developing the disease. Whether the problem is an enzyme deficiency in
23

carbohydrate metabolism or the excessive triplet repeats that characterize the mutation for
Huntington chorea does not matter. The biochemical or genetic abnormality is no more a
definition of a disease state than a positive result on a purifiedprotein-derivative (PPD) skin test
is for tuberculosis. The issue is not an academic one. In view of the desire of insurance carriers to
avoid pre-existent illnesses, the issue of when someone gets a disease is currently a matter of
intense ethical and legal concern. One gets a disease when one has symptoms, not merely signs,
that point to the disease, and not before that time.
Watson and Crick's work, and the work of both their acknowledged and unacknowledged
collaborators in the 1950s, led to the unraveling of the genetic code, the recognition that the code
of both DNA and RNA had to be read from a specific end of the macromolecule, the
understanding that both DNA and RNA sequences are decoded in triplets, and the recognition
that a triplet codes for only one amino acid. These triplets are called codons. (Later work showed
that some codons do not code for an amino acid. Some mark the beginning or end of a peptide
chain.) Molecular biologists do not know the function of some long sequences of codons called
introns. Once we understood clearly how DNA codes for a protein, we recognized that an amino
acid substitution in a protein must result from a change in the mRNA triplet as a result of a
mutation in the corresponding DNA (the gene).
At first, clinical and biochemical investigations led to recognition of the consequences of altered
protein products and to an understanding of how these might produce disease. The new
molecular techniques led to a reverse approach. Alterations in DNA were traced to RNA changes.
Science is only now on the verge of explaining some of these as changes in proteins.[6] This
approach from DNA back flourished in the 1980s and 1990s as various methods were developed

24

that showed alterations in the structure of nucleic acid chains independent of other aspects of
biochemistry or biology.
One technique, called restriction fragment length polymorphism (RFLP) analysis, includes
cutting DNA into fragments by using one or more bacterial enzymes, each with a specific nucleic
acid recognition site that directs where the DNA is to be cut. The lengths of the fragments then
are measured on the basis of their migration within a gel when exposed to an electrical current.
Another technique, polymerase chain reaction (PCR), converts traces of DNA into large amounts
of identical material. Scientists can analyze the genetic material once it has been magnified this
way. These techniques have totally changed research on inherited diseases. They are similar to
the methods society currently uses to identify each of us as individuals (by DNA fingerprinting)
and to infer how we and other species may have evolved (by analyses of nuclear and
mitochondrial DNA in individuals, even individuals dead for millions of years, and in species
and in populations of species).
CHAPTER14
The role of the immune system a collection of structures and processes within the body is
to protect against disease or other potentially damaging foreign bodies. When functioning
properly, the immune system identifies a variety of threats, including viruses, bacteria and
parasites, and distinguishes them from the body's own healthy tissue, according to Merck
Manuals.
The major components of the immune system include:
Lymph nodes: Small, bean-shaped structures that produce and store cells that fight infection and
disease and are part of the lymphatic system which consists of bone marrow, spleen, thymus
25

and lymph nodes, according to "A Practical Guide To Clinical Medicine" from the University of
California San Diego (UCSD). Lymph nodes also contain lymph, the clear fluid that carries those
cells to different parts of the body. When the body is fighting infection, lymph nodes can become
enlarged and feel sore.
Spleen: The largest lymphatic organ in the body, which is on your left side, under your ribs and
above your stomach, contains white blood cells that fight infection or disease. According to the
National Institutes of Health (NIH), the spleen also helps control the amount of blood in the body
and disposes of old or damaged blood cells.
Bone marrow: The yellow tissue in the center of the bones produces white blood cells. This
spongy tissue inside some bones, such as the hip and thigh bones, contains immature cells, called
stem cells, according to the NIH. Stem cells, especially embryonic stem cells, which are derived
from eggs fertilized in vitro (outside of the body), are prized for their flexibility in being able to
morph into any human cell.
Lymphocytes: These small white blood cells play a large role in defending the body against
disease, according to the Mayo Clinic. The two types of lymphocytes are B-cells, which make
antibodies that attack bacteria and toxins, and T-cells, which help destroy infected or cancerous
cells. Killer T-cells are a subgroup of T-cells that kill cells that are infected with viruses and other
pathogens or are otherwise damaged. Helper T-cells help determine which immune responses the
body makes to a particular pathogen.
Thymus: This small organ is where T-cells mature. This often-overlooked part of the immune
system, which is situated beneath the breastbone (and is shaped like a thyme leaf, hence the
name), can trigger or maintain the production of antibodies that can result in muscle weakness,
26

the Mayo Clinic said. Interestingly, the thymus is somewhat large in infants, grows until puberty,
then starts to slowly shrink and become replaced by fat with age, according to the National
Institute of Neurological Disorders and Stroke.
Leukocytes: These disease-fighting white blood cells identify and eliminate pathogens and are
the second arm of the innate immune system. A high white blood cell count is referred to as
leukocytosis, according to the Mayo Clinic. The innate leukocytes include phagocytes
(macrophages, neutrophils and dendritic cells), mast cells, eosinophils and basophils.
Diseases of the immune system
If immune system-related diseases are defined very broadly, then allergic diseases such as
allergic rhinitis, asthma, and eczema are very common. However, these actually represent a
hyper-response to external allergens, according to Dr. Matthew Lau, chief, department of allergy
and immunology at Kaiser Permanente Hawaii. Asthma and allergies also involve the immune
system. A normally harmless material, such as grass pollen, food particles, mold or pet dander, is
mistaken for a severe threat and attacked.
Other dysregulation of the immune system includes autoimmune diseases such as lupus and
rheumatoid arthritis. "Finally, some less common disease related to deficient immune system
conditions are antibody deficiencies and cell mediated conditions that may show up
congenitally," Lau told Live Science.
Disorders of the immune system can result in autoimmune diseases, inflammatory diseases and
cancer, according to the NIH.

27

Immunodeficiency occurs when the immune system is not as strong as normal, resulting in
recurring and life-threatening infections, according to the University of Rochester Medical
Center. In humans, immunodeficiency can either be the result of a genetic disease such as severe
combined immunodeficiency, acquired conditions such as HIV/AIDS, or through the use of
immunosuppressive medication.
On the opposite end of the spectrum, autoimmunity results from a hyperactive immune system
attacking normal tissues as if they were foreign bodies, according to the University of Rochester
Medical Center. Common autoimmune diseases include Hashimoto's thyroiditis, rheumatoid
arthritis, diabetes mellitus type 1 and systemic lupus erythematosus. Another disease considered
to be an autoimmune disorder is myasthenia gravis (pronounced my-us-THEE-nee-uh GRAYvis).
Diagnosing diseases of the immune system
Even though symptoms of immune diseases vary, fever and fatigue are common signs that the
immune system is not functioning properly, the Mayo Clinic noted.
Most of the time, immune deficiencies are diagnosed with blood tests that either measure the
level of immune elements or their functional activity, Lau said.

Allergic conditions may be evaluated using either blood tests or allergy skin testing to identify
what allergens trigger symptoms.
How are immune deficiency diseases commonly treated?

28

In overactive or autoimmune conditions, medications that reduce the immune response, such as
corticosteroids or other immune suppressive agents, can be very helpful. "In some immune
deficiency conditions, the treatment may be replacement of missing or deficiency elements," Lau
said. "This may be infusions of antibodies to fight infections."
Treatment may also include monoclonal antibodies, Lau said. A monoclonal antibody is a type of
protein made in a lab that can bind to substances in the body. They can be used to regulate parts
of the immune response that are causing inflammation, Lau said. According to the National
Cancer Institute, monoclonal antibodies are being used to treat cancer. They can carry drugs,
toxins or radioactive substances directly to cancer cells.
Who treats the immune system?
An allergist/immunologist is a physician specially trained to diagnose, treat and manage
allergies, asthma and immunologic disorders, including primary immunodeficiency disorders,
according to the American College of Asthma, Allergy and Immunology (ACAAI). These
conditions range from common to extremely rare, spanning all ages and encompassing various
organ systems.
To become an allergist/immunologist, physicians must undergo three years of training in internal
medicine or pediatrics after completing medical school and graduating with a medical degree,
according to the ACAAI. They must also pass the exam of either the American Board of Internal
Medicine (ABIM) or the American Board of Pediatrics (ABP).
Internists and pediatricians must undergo a two-year fellowship in an allergy/immunology
training program to become an allergist/immunologist, the ACAAI said.

29

CHAPTER15
CLINICAL ENZYMOLOGY

PLASMA ENZYMES

Measurements of the activity of enzymes in plasma are of value in the diagnosis and
management of a wide variety of diseases. Most enzymes measured in plasma are primarily
intracellular, being released into the blood when there is damage to cell membranes, but many
enzymes, for example renin, complement factors and coagulation factors, are actively secreted
into the blood, where they fulfil their physiological functions.
Small amounts of intracellular enzymes are present in the blood as a result of normal cell
turnover. When damage to cells occurs, increased amounts of enzymes will be released and their
concentrations in the blood will rise. However, such increases are not always due to tissue
damage. Other possible causes include:

increased cell turnover

cellular proliferation (e.g. neoplasia)

increased enzyme synthesis (enzyme induction)

obstruction to secretion

decreased clearance.

Little is known about the mechanisms by which enzymes are removed from the circulation.
Small molecules, such as amylase, are filtered by the glomeruli but most enzymes are probably
removed by reticuloendothelial cells. Plasma amylase activity rises in acute renal failure but, in
30

general, changes in clearance rates are not known to be important as causes of changes in plasma
enzyme levels.

CLINICAL ENZYMOLOGY

Plasma contains many functional enzymes, which a actively secreted into plasma. For example,
enzymes blood coagulation. On the other hand, there are a few non functional enzymes in
plasma, which are coming out from cells of various tissues due to normal wear and tear. Their
normal levels in blood are very low; but are drastically increased during cell death (necrosis) or
disease. Therefore assays of these enzymes are very useful in diagnosis diseases.
Enzyme Units
Enzyme assays usually depend on the measurement the catalytic activity of the enzyme, rather
than the concentration of the enzyme protein itself. Since each enzyme molecule can catalyze the
reaction of many molecules of substrate, measurement of activity provides great sensitivity. It is,
however, important that the conditions of the assay are optimized and standardized to give
reliable and reproducible results. Reference ranges for plasma enzymes are dependent on assay
conditions, for example temperature, and may also be subject to physiological influences. It is
thus important to be aware of both the reference range for the laboratory providing the assay and
the physiological circumstances when interpreting the results of enzyme assays.
One international unit is the amount of enzyme that will convert one micromole of substrate per
minute per litre of sample and is abbreviated as U/L. The SI Unit (System Internationale)
expression is more scientific, where or Katal (catalytic activity) is defined as the number of mole

31

of substrate transformed per second per litre of sample. Katal is abbreviated as kat or k (60 U = 1
kat and 1 nk = 0.06 U).
Disadvantages of enzyme assays
A major disadvantage in the use of enzymes for the diagnosis of tissue damage is their lack of
specificity to a particular tissue or cell type. Many enzymes are common to more than one tissue,
with the result that an increase in the plasma activity of a particular enzyme could reflect damage
to any one of these tissues. This problem may be obviated to some extent in two ways:
first, different tissues may contain (and thus release when they are damaged) two or more
enzymes in different proportions; thus alanine and aspartate aminotransferases are both present
in cardiac and skeletal muscle and hepatocytes, but there is only a very little alanine
aminotransferase in either type of muscle;
second, some enzymes exist in different forms (isoforms), colloquially termed isoenzymes
(although, strictly, the term 'isoenzyme' refers only to a genetically determined isoform).
Individual isoforms are often characteristic of a particular tissue: although they may have similar
catalytic activities, they often differ in some other measurable property, such as heat stability or
sensitivity to inhibitors.
After a single insult to a tissue, the activity of intracellular enzymes in the plasma rises as they
are released from the damaged cells, and then falls as the enzymes are cleared. It is thus
important to consider the time at which the blood sample is taken in relation to the insult. If
taken too soon, there may have been insufficient time for the enzyme to reach the blood- stream
and if too late, it may have been completely cleared. As with all diagnostic techniques, data
acquired from measurements of enzymes in plasma must always be assessed in the light of
whatever clinical and other information is available, and their limitations borne in mind.

32

LACTATE DEHYDROGENASE (LDH) (LD)


The total LDH is generally tested by reaction of the serum sample with pyruvate and NADH2.
LDH will convert pyruvate to lactate, and in turn NADH is use up by the reaction.
Normal value of LDH in serum is 100-200 U/L. Values the upper range are generally seen in
children. Strenuous exercise will slightly increase the value. LDH level is 100 times more inside

33

the RBC than in plasma, and therefore minor amount of hemolysis will result in a false-positive
test.
LDH and Heart Attack
In myocardial infarction, total LDH activity is increased, while H4 iso-enzyme is increased 5-10
times more.
Differential diagnosis: Increase in total LDH level is seen in hemolytic anemias, hepatocellular
damage, muscular dystrophy, carcinomas, leukemias, and any condition which causes necrosis
of body cells. Since total LDH is increased in many conditions, the study of isozymes of LDH is
of great importance.
Isoenzymes of LDH
LDH enzyme is a tetramer with four subunits. But the subunit may be either H (heart) or M
(muscle) polypeptide chains. These two are the products of two different genes.
Although both of them have the same molecular weight (32 kD), there are minor amino acid
variations. So five combinations of H and M chains are possible; H4, H3M, H2M2, M3H and
M4 varieties, forming five iso-enzymes. All these five forms are seen in all persons. M4 form is
seen in skeletal muscles; it is not inhibited by pyruvate. But H4 form is seen in heart and is
inhibited by pyruvate. Normally LDH-2 (H3M1) concentration in blood is greater than LDH-1
(H4); but this pattern is reversed in myocardial infarction; this is called flipped pattern. The isoenzymes are usual ly separated by cellulose acetate electrophoresis at pH 8.6. They are then
identified by adding the reactants finally producing a colour reaction. . Lactate dehydrogenase
isoenzymes (as percentage of total):

LDH1

14-26 %

34

LDH2

29-39 %

LDH3

20-26 %

LDH4

8-16%

LDH5

6-16 %

CREATINE KINASE(CK)
It is used for the reaction shown in Figure:
Creatine

Creatine phosphate

It was called as creatine phosphokinase in old literature.


Normal serum value for CK is 15-100 U/L for males and 10-80 U/L for females.
CK and Heart Attack CK value in serum is increased in myocardial infarction. The CK level
starts to rise within three hours of infarction. Therefore, CK estimation is very useful to detect
early cases, where ECG changes may be ambiguous. The CK level is not increased in hemolysis
or in congestive cardiac failure; and therefore CK has an advantage over LDH.
CK and Muscle Diseases he level of CK in serum is very much elevated in muscular dystrophies
(500 -1500 IU/L). The level is very high in the early phases of the disease. In such patients a fall
in CK level is indicative of deteriorating condition, because by that time, all muscle mass is
destroyed. In female carriers of this X-linked disease (genotypically heterozygous), CK is seen to
be moderately raised. CK level is highly elevated in crush injury, fracture and acute
cerebrovascular accidents. Estimation of total CK is employed in muscular dystrophies and MB
iso-enzyme is estimated in myocardial infarction.

35

Iso-enzymes of CK CK is a dimer; each subunit has a molecular weight of 40,000. The subunits
are called B for brain and M for muscle. They are products of loci in chromosomes 14 and 19
respectively. Therefore three iso-enzymes are seen in circulation. Normally CK2 is only 5% of
the total activity. Even doubling the value in CK2 (MB) iso-enzyme may not be detected, if total
value of CK alone is estimated. Hence the detection of MB-iso-enzyme is important in
myocardial infarction. CK-MB < 6 % of total CK in normal conditions.
The above three iso-enzymes are cytosolic. A fourth variety, called CK-mt is located in
mitochondria and constitutes about 15% of total CK activity. Its gene is located in
chromosome 15. CK1 may be complexed with immunoglobulin; and then termed macroCK.
CK1-lgG causes false-positive diagnosis of myocardial infarction because it has an
electrophoretic mobility close to CK2.
For quantitating MB iso-enzyme, anti-MM antiserum is added to the patient's serum.
This will precipitate MM iso-enzyme. The supernatant serum is used for the CK estimation.
Here it is assumed that BB isoenzyme is negligible in quantity, which is correct if there is no
brain disease. CK iso-enzymes can also be identified by electrophoresis.
TRANSFERASES
AST present in cytosol and mitochondria
ALT located in cytosol of liver
In the liver, the concentration of ALT per unit weight of the tissue is more than AST.
These enzymes are more important in assessing and monitoring the degree of liver cell
inflammation and necrosis.
The highest activities of ALT are found in hepatocytes and muscle cells.
Again the hepatocytes have very high activity of ALT.

36

Therefore elevations in serum ALT are considered to be relatively specific for liver
disease.
AST may be elevated in other forms of tissue damage, such as myocardial infarction,
muscle necrosis and renal disorders.
In liver disease, the ALT level is increased markedly compared to AST.
In acute viral hepatitis there is a 100-1000 times increase in both ALT and AST but ALT
level is increased more than that of AST

ASPARTATE AMINO TRANSFERASE (AST)


It is also called as serum glutamate-oxaloacetate transaminase (SGOT). AST needs pyridoxal
phosphate as co-enzyme. AST is estimated by taking aspartate, -ketoglutarate, pyridoxal
phosphate (vitamin B6) and patient' serum as the source of AST. The oxaloacetate formed may
be allowed to react with dinitrophenyl hydrazine to produce a colour which is estimated
colorimetrically at 520 nm.
Normal serum level of AST is 8-40 U/L or (0,1-0,45 mmol/(hourL))
It is significantly elevated in myocardial infarction. It if moderately elevated in liver diseases.
However, a marked increase in AST may be seen in primary hepatoma. AST has two isoenzymes; cytoplasmic and mitochondrial. In mile degree of tissue injury, cytoplasmic form is
seen in serum. Mitochondrial type is seen in severe injury.
Marked increase (10 to 100 times the upper adult reference limit):
Circulatory failure with 'shock' and hypoxia:
Myocardial infarction
Acute viral or toxic hepatitis.

37

Moderate increase
Cirrhosis (may be normal, but may rise to twice the upper adult reference limit):
Infectious mononucleosis (due to liver involvement):
Cholestatic jaundice (up to 10 times the upper adult reference limit):
Malignant infiltration of the liver (may be normal, but may rise to twice the upper reference
limit):
Skeletal muscle disease:
After trauma or surgery (especially after cardiac surgery):
Severe haernolytic episodes (of erythrocyte origin).
ALANINE AMINO TRANSFERASE (ALT)
It is also called as serum glutamate-pyruvate transaminase (SGPT). ALT needs pyridoxal
phosphate as co-enzyme.
Normal serum level of ALT is 5-30 U/L or (0,1-0,68 mmol/(hourL))
Very high values (100 to 1000 U/L) are seen in acute hepatitis, either toxic or viral in origin.
Both ALT and AST are increased in liver diseases, but ALT >AST. Moderate increase (25 to
100 U/L) may be seen in chronic liver disease such as cirrhosis, and malignancy in liver. A
sudden fall in ALT level in cases of hepatitis is a very bad prognostic sign.
Ritis coefficient (AST/ALT) in normal conditions is 1,330,42.
Marked increase (10 to 100 times the upper limit of the adult reference range circulatory
failure with 'shock' and hypoxia:
Acute viral or toxic hepatitis.
Moderate increase:
Cirrhosis (may be normal or up to twice the upper adult reference limit): infectious

38

mononucleosis (due to liver involvement):


Liver congestion secondary to congestive cardiac failure:
cholestatic jaundice (up to 10 times the upper reference limit in adults); surgery or
extensive trauma and skeletal muscle disease (much less affected than AST)

Alkaline phosphatase (ALP)


It is a non- specific enzyme which hydrolyses aliphatic, aromatic or heterocyclic compounds.
The pH optimum for the enzyme reaction is between 9 and 10. It is prodused by osteoblasts of
bone, and localized in cell memmbranes (ecto-enzyme).
Normal serum level of ALP is 40-125 U/L or 0,5-1,3 mmol/(hour L).
In children the upper level of normal value may be more, becouse of the increased osteoblastic
activity. Mild increase is noticed during pregnancy, due to production of placental isoenzyme.
Moderate (2-3 times) increase in ALP level is seen in hepatic diseases such as hepatitis,
alcoholic hepatosis or hepatocellular carcinoma. Very high levels of ALP (10-12 times of upper
limit) may be noticed in extrahepatic obstructions or cholestasis. ALP is produced by epithelial
cells of biliary canaliculi and obstruction of bile with consequent irritation of epithelial cells
leads to secretion of ALP into serum.
Drastically high levels of ALP (10-25 times of upper limit) are also seen in bone diseases
where osteoblastic activity is enhanced such as Paget's disease, rickets, osteomalacia,
osteoblastoma, metastatic carcinoma of bone and hyperparathyroidism (Paget's disease or
osteitis deformans was described in 1877 by Sir James Paget).
Iso-enzymes of Alkaline Phosphatase

39

1.

-1 ALP moves in -1 position, it is synthesised by epithelial cells of biliary

canaliculi. It is about 10% of total activity and is increased in obstructive jaundice and to some
extent in metastatic carcinoma of liver.
2.

-2 heat labile ALP is stable at 56C; but loses its activity when kept at 65C for

30 minutes. It is produced by hepatic cells. Therefore absence of -1 with exaggerated -2


band suggests hepatitis. This liver iso-enzyme forms about 25% of total ALP.
3.

-2 heat stable ALP will not be destroyed at 65 C but is inhibited by

phenylalanine. It is of placental origin, which is found in blood in normal pregnancy. An isoenzyme closely resembling the placental form is characteristically seen in circulation in about
15% cases of carcinoma of lung, liver and gut and named as Regan isoenzyme (after the first
patient in whom it was detected or carcinoplacental iso-enzyme. Chronic heavy smoking also
increases Regan iso-enzyme level in blood. Normal level is only 1 % of the total ALP.
4.

Pre- ALP is of bone origin and elevated levels are seen in bone diseases. This is

the most heat labile (destroyed at 56C, 10 min). Wheat germ lectin will precipitate bone isoenzyme. This constitutes about 50% of normal ALP activity.
5.

-ALP is inhibited by phenylalanine and originates from intestinal cells. It is

increased in ulcerative colitis. About 10% of plasma ALP are of intestinal variety.
6.

The leucocyte alkaline phosphatase (LAP) is significantly decreased in chronic

myeloid leukemia. It is increased in lymphomas.


ALP has different isoforms. Although ALP is a monomer, depending on the number of
sialic acid residues, the charged groups differ. Such different forms are detected in agar gel
electrophoresis.

40

NUCLEOTIDE PHOSPHATASE (NTP)


It is also known as 5' nucleotidase. This enzyme hydrolyses 5' nucleotides to corresponding
nucleosides at an optimum pH of 7.5. It is a marker enzyme for plasma membranes and is seen
as an ecto-enzyme (enzyme present on the cell membrane).
Usually, AMP is used as substrate, which is hydrolysed to adenosine and inorganic
phosphate. The latter reacts with ammonium molybdate to produce the yellow ammonium
phosphomolybdate, which is estimated colorimetrically. However, ALP will also catalyse the
same reaction. Serum samples contain both ALP and NTP. These are distinguished by Nickel
ions which inhibit NTP but not ALP.
Normal NTP level in serum is 2-10 U/L. It is moderately increased in hepatitis and highly
elevated in biliary obstruction. Unlike ALP, the level is unrelated with osteoblastic activity and
therefore is unaffected by bone diseases.

GAMMA GLUTAMYL TRANSFERASE (GGT)


The old name was gamma glutamyl transpeptidase. It can transfer -glutamyl residues to
substrate. In the body it is used in the synthesis of glutathione. GGT has 11 iso-enzymes. It is
seen in liver, kidney, pancreas, intestinal cells and prostate gland.
Normal serum value of GGT is 6-45 U/L in male and 5-30 U/L in female. It is slightly higher in
normal males, due to the presence of prostate gland. This value is moderately increased in
infective hepatitis and prostate cancers. The GGT level is highly elevated in alcoholism,
obstructive jaundice and neoplasm's of liver. GGT-2 is positive for 90% of hepatocellular
carcinomas. It is not elevated in cardiac or skeletal diseases.

41

GGT is a microsomal enzyme. Its activity is induced by alcohol, phenobarbitone and rifampicin.
GGT is clinically important because of its sensitivity to detect alcohol abuse. GGT is increased
in alcoholics even when other liver function tests are within normal limits. GGT level is rapidly
decreased within a few days when the person stops to take alcohol. Increase in GGT level is
generally proportional to the amount of alcohol intake.
ACID PHOSPHATASE (ACP)
It hydrolyses phosphoric acid ester at pH between 4 and 6. Methods for assay are the same as
described for ALP; but the pH of the medium is kept at 5 to 5.4.
Normal serum value for ACP is 2.5-12 U/L or 0,025-0,12 mmol/(hour L).
ACP is secreted by prostate cells, RBC, platelets and WBC. Isoenzymes of ACP are described.
Erythrocyte ACP gene is located in chromosome 2; osteoclast ACP gene is on chromosome 19;
lysosomal gene is on 11 and prostate ACP gene is on 13. The prostate iso-enzyme is inactivated
by tartaric acid. Cupric ions inhibit erythrocyte ACP. Normal level of tartrate labile fraction of
ACP is 1 U/L.
ACP total value is increased in prostate cancer and highly elevated in bone metastasis of prostate
cancer. In these conditions, the tartrate labile iso-enzyme is elevated. This assay is very helpful
in follow up of treatment of prostate cancers. ACP is therefore an important tumour marker.
Since blood cells contain excess quantity of ACP, must be taken to prevent hemolysis while
taking blood from the patient. Prostate massage may also increase to value. So blood may be
collected for ACP estimation before per rectal examination of patient. ACP is present in high
concentration in semen, a finding which is used in forensic medicine in investigation of rape.
The main indications for estimation are to help diagnose prostatic carcinoma and to monitor its
treatment. The estimation is gradually being replaced by the measurement of plasma prostate

42

specific antigen (PSA) a protein derived from the prostate. This test is more specific and
sensitive for diagnosis and monitoring treatment. However, it may be raised in similar
circumstances to those affecting prostatic ACP and is more expensive to estimate. ACP is more
useful for monitoring the treatment of a known case of disseminated prostatic carcinoma than for
making the diagnosis.

PROSTATE SPECIFIC ANTIGEN (PSA)


It is produced from the secretory epithelium of prostal gland. It is normally secreted into seminal
fluid, where it is necessary for the liquefaction of seminal coagulum. It is a serine protease, and
is a 32 kD glycoprotein; encoded in chromosome number 19. In blood it is bound to alpha-2
macroglobulin and alpha-1-antitrypsin; a very smal fraction is in the free from also.
Normal value is 1 -5 g/L. It is very specific for prostate activity. Values between 4-10 g/L is
seen in benign prostate enlargement; but values above 10 g/L is indicative of prostate cancer.

CHOLINESTERASE (ChE)
Acetyl cholinesterase or true ChE or Type 1 ChE can act mainly on acetyl choline. It is present
in nerve endings and in RBCs. About 25 allelic forms are reported. Normal serum range is 2-12
U/ml. Newly formed RBC will contain good quantity of ChE which is slowly reduced according
to the age of the cell. Therefore, ChE level in RBCs will be proportional to the reticulocyte
count. Organophosphorus insecticides (Parathione) irreversibly inhibit ChE in RBCs.
Measurement of ChE level in RBCs is useful to determine the amount of exposure in persons
working with these insecticides.

43

Pseudocholinesterase or type II ChE is non-specific and can hydrolyse acyl esters. It is produced
mainly by liver cells. Normal serum level is 8-18 U/ml. Succinyl choline is a widely used as
muscle relaxant. It is a structural analogue of ACh, and so competitively fix on post-synaptic
receptors of ACh. Succinyl choline is hydrolysed by the liver ChE within 2-4 minutes. But in
certain persons the ChE activity may be absent; this is a genetically transmitted condition. In
such individuals when succinyl choline is given during surgery, it may take hours to get the drug
metabolised. Very prolonged scoline apnoea may result in 'nightmare of anaesthetist'. The
pseudocholinesterase level in serum is reduced in viral hepatitis, cirrhosis, hepatocellular
carcinoma, metastatic cancer of liver and in malnutrition.
Causes of decreased plasma cholinesterase activity
Hepatic parenchymal disease (reduced synthesis).
Ingestion or absorption through the skin, of such anticholinesterases as organophosphates.
Inherited abnormal cholinesterase variants, with low biological activity.
Causes of increased plasma cholinesterase activity
a. Recovery from liver damage (actively growing hepatocytes)
b. Nephrotic syndrome

GLUCOSE-6-PHOSPHATE DEHYDROGENASE
GPD is a dimer with identical subunits. This is an important enzyme in the hexose
monophosphate shunt pathway of glucose. It is mainly used for production of NADPH . It has a
special role in the RBC metabolism. Due to the presence of oxygen, hydrogen peroxide is
continuously formed inside the RBC. Peroxide will destroy biomembranes, and RBCs are lysed.

44

Normal value of GPD in RBC is 125-250 U/1012 cells. Nearly 400 variants (isoforms) of GPD
are described.

AMYLASE
This splits starch to maltose. It is activated by calcium, chloride and fluoride ions. There are 18
phenotypes. It is produced by pancreas and salivary glands; they are products of different genes
located in chromosome 1.
Normal serum value is 50-120 U/L, (12-32 g/(hour L)).
The value is increased about 1000 times in acute pancreatitis which is a life-threatening
condition. The peak values are seen between 5-12 hours after the onset of disease and returns to
normal levels within 2-4 days after the acute phase has subsided. Moderate increase in serum
levels are seen in chronic pancreatitis, mumps (parotitis), obstruction of pancreatic duct and in
renal disease. In the last condition, the enzyme is not excreted through urine properly and hence
serum value is raised. Normal urine value is 20-160 g/(hour L) or (less than 375 U/L). It is
increased in acute pancreatitis. It is increased on the 1 st day and remains to be elevated for 7-10
days.

LIPASE
It will hydrolyse triglyceride to -monoglyceride and fatty acid. Molecular weight is 54,000. The
gene is in chromosome 10. The enzyme is present in pancreatic secretion.Normal serum range is
0.2-1.5 U/L. It is highly elevated in acute pancreatitis and this persists for 7-14 days. Thus, lipase
remains elevated longer than amylase. Moreover, lipase is not increased in mumps. Therefore,

45

lipase estimation has advantage over amylase. It is moderately increased in carcinoma of


pancreas, biliary diseases and perforating peptic ulcers.

Aldolase (ALD)
It is a tetrameric enzyme with A and B subunits; so there are 5 iso-enzymes. It is a glycolytic
enzyme. Normal range of serum is 1.5-7 U/L. It is drastically elevated in muscle damages such
as progressive muscular dystrophy, poliomyelitis, myasthenia gravis and multiple sclerosis. It is
a very sensitive early index in muscle wasting diseases.

Enolase
It is a glycolytic enzyme. Neuron-specific enolase (NSE) is an iso-enzyme seen in neural tissues
and Apudomas. NSE is a tumour marker for cancers associated with neuro-endocrine origin,
small cell lung cancer, neuroblastoma, pheochromocytoma, medullary carcinoma of thyroid, etc.

46

It is measured by RIA or ELISA. Upper limit of NSE is 12 g/ml.

Enzymes in Malignancy

47

Plasma total enzyme activities may be raised or an abnormal isoenzyme detected, in


several neoplastic disorders.
Serum prostatic (tartrate-labile) acid phosphatase activity rises in some cases of malignancy of
the prostate gland.
Any malignancy may be associated with a non-specific increase in plasma LD1 (HBD) and
occasionally, transaminase activity.
Plasma transaminase and alkaline phosphatase estimations may be of value to monitor
treatment of malignant disease. Raised levels may indicate secondary deposits in liver or of
alkaline phosphatase, in bone. Liver deposits may also cause an increase in plasma LD or GGT.
Tumors occasionally produce a number of enzymes, such as the 'Regan' ALP isoenzyme.'
LD (HBD) or CK-BB. assays of which may be used as an aid to diagnosis or for monitoring
treatment.
Other Clinical correlations
1. Niemann-Pick disease: Acid Sphingomyelinase Deficiency
Sphingomyelin, a ubiquitous component of cell membranes, especially neuronal membranes, is
normally degraded within lysosomes by the enzyme sphingomyelinase.
In patients with Niemann-Pick disease, inherited deficiency of this enzyme causes
spingomyelin to accumulate in lysosomes of the brain, bone marrow, and other organs.
Enlargement of the lysosomes interferes with their normal function, leading to cell death and
consequent neuropathy.
Symptoms include failure to thrive and death in early childhood as well as learning disorders in
those who survive the postnatal period.
2. Homocysteinuria: Cystathionine -synthase Deficiency

48

1. Cystathionine -synthase catalyzes conversion of homocysteine to cystathionine, a critical


precursor of cysteine.
2. Deficiency of this enzyme leads to the most common form of homocystinuria, a pediatric
disorder characterized by accumulation of homocysteine and reduced activity of several
sulfotransferase reactions that require this compound or its derivatives as substrate.
3. Accumulation of homocysteine and reduced transsulfation of various compounds leads to
abnormalities in connective tissue structures that cause altered blood vessel wall structure, loss of
skeletal bone density (osteoporosis), dislocated optic lens (ectopia lentis), and increased risk of
blood clots.
3. Enzyme Replacement Therapy for Inborn Errors of Metabolism
Lysosomal enzyme deficiencies, which frequently result in disease due to accumulation of the
substrate for the missing enzyme, are suitable targets for enzyme replacement therapy (ERT).
In ERT, intravenously administered enzymes are taken up directly by the affected cells through
a receptor-mediated mechanism.
ERT provides temporary relief of symptoms but must be given repeatedly and is not a
permanent cure.

Summary
1. Enzyme concentrations are high in cells. Natural decay of these cells releases enzymes into the
plasma. Plasma activities are usually low but measurable.
2. Plasma enzyme assays are most useful in the detection of raised levels due to cell damage.

49

3. Assays of selected enzymes may help to identify the damaged tissues and isoenzyme studies
may increase the specificity. In general, knowledge of the patterns of enzyme changes, together
with the clinical and other findings, are needed if a useful interpretation is to be made.
4. Non-specific causes of raised enzyme activities include peripheral circulatory insufficiency,
trauma, malignancy and surgery.
5. Artefactual increases may occur in haemolysed samples.
6. Enzyme estimations may be of value in the diagnosis and monitoring of:
a. Myocardial infarction (CK. LD and its isoenzymes and sometimes AST);
b. Liver disease (transaminases. ALP and sometimes GGT):
c. Bone disease (ALP):
d. Prosratic carcinoma (tartrate-labile ACP);
e. Acute pancreatitis (-amylase):
f. Muscle disorders (CK)

CHAPTER16
Liver disease is any disturbance of liver function that causes illness. The liver is responsible for
many critical functions within the body and should it become diseased or injured, the loss of
those functions can cause significant damage to the body. Liver disease is also referred to as
hepatic disease.
Liver disease is a broad term that covers all the potential problems that cause the liver to fail to
perform its designated functions. Usually, more than 75% or three quarters of liver tissue needs
to be affected before decrease in function occurs.
50

The liver is the largest solid organ in the body; and is also considered a gland because among its
many functions, it makes and secretes bile. The liver is located in the upper right portion of the
abdomen protected by the rib cage. It has two main lobes that are made up of tiny lobules. The
liver cells have two different sources of blood supply. The hepatic artery supplies oxygen rich
blood that is pumped from the heart, while the portal vein supplies nutrients from the intestine
and the spleen.
Normally, veins return blood from the body to the heart, but the portal vein allows chemicals
from the digestive tract to enter the liver for "detoxification" and filtering prior to entering the
general circulation. The portal vein also efficiently delivers the chemicals and proteins that liver
cells need to produce the proteins, cholesterol, and glycogen required for normal body activities.

The liver plays an important role in many bodily functions from protein
production and blood clotting to cholesterol, glucose and iron
metabolism.

A variety of illnesses can affect the liver.

Cirrhosis occurs when normal liver cells are replaced by scar tissue as a
result of chronic liver disease.

Symptoms of liver diseases include weakness and fatigue, weight loss,


nausea, vomiting, and yellow discoloration of the skin (jaundice).

The treatment of a particular liver disease depends on its specific cause.

CHAPTER17

51

Tumor markers are substances that are produced by cancer or by other cells of the body in
response to cancer or certain benign (noncancerous) conditions. Most tumor markers are made
by normal cells as well as by cancer cells; however, they are produced at much higher levels in
cancerous conditions. These substances can be found in the blood, urine, stool, tumor tissue, or
other tissues or bodily fluids of some patients with cancer. Most tumor markers are proteins.
However, more recently, patterns of gene expression and changes to DNA have also begun to be
used as tumor markers. Markers of the latter type are assessed in tumor tissue specifically.
Thus far, more than 20 different tumor markers have been characterized and are in clinical use.
Some are associated with only one type of cancer, whereas others are associated with two or
more cancer types. There is no universal tumor marker that can detect any type of cancer.
There are some limitations to the use of tumor markers. Sometimes, noncancerous conditions can
cause the levels of certain tumor markers to increase. In addition, not everyone with a particular
type of cancer will have a higher level of a tumor marker associated with that cancer. Moreover,
tumor markers have not been identified for every type of cancer.
Tumor markers are used to help detect, diagnose, and manage some types of cancer. Although an
elevated level of a tumor marker may suggest the presence of cancer, this alone is not enough to
diagnose cancer. Therefore, measurements of tumor markers are usually combined with other
tests, such as biopsies, to diagnose cancer.
Tumor marker levels may be measured before treatment to help doctors plan the appropriate
therapy. In some types of cancer, the level of a tumor marker reflects the stage (extent) of the
disease and/or the patients prognosis (likely outcome or course of disease). More information
about staging is available in the NCI fact sheet Cancer Staging.
52

Tumor markers may also be measured periodically during cancer therapy. A decrease in the level
of a tumor marker or a return to the markers normal level may indicate that the cancer is
responding to treatment, whereas no change or an increase may indicate that the cancer is not
responding.
Tumor markers may also be measured after treatment has ended to check for recurrence (the
return of cancer).
CHAPTER18
PPorphyrin, any of a class of water-soluble, nitrogenous biological pigments (biochromes),
derivatives of which include the hemoproteins (porphyrins combined with metals and protein).
Examples of hemoproteins are the green, photosynthetic chlorophylls of higher plants; the
hemoglobins in the blood of many animals; the cytochromes, enzymes that occur in minute
quantities in most cells and are involved in oxidative processes; and catalase, also a widely
distributed enzyme that accelerates the breakdown of hydrogen peroxide.
Porphyrins have complex cyclic structures. All porphyrin compounds absorb light intensely at or
close to 410 nanometres. Structurally, porphyrin consists of four pyrrole rings (five-membered
closed structures containing one nitrogen and four carbon atoms) linked to each other by methine
groups (CH=). The iron atom is kept in the centre of the porphyrin ring by interaction with the
four nitrogen atoms. The iron atom can combine with two other substituents; in oxyhemoglobin,
one substituent is a histidine of the protein carrier, and the other is an oxygen molecule. In some
heme proteins, the protein is also bound covalently to the side chains of porphyrin.

53

Green chromoproteins called biliproteins are found in many insects, such as grasshoppers, and
also in the eggshells of many birds. The biliproteins are derived from the bile pigment biliverdin,
which in turn is formed from porphyrin; biliverdin contains four pyrrole rings and three of the
four methine groups of porphyrin. Large amounts of biliproteins, the molecular weights of which
are about 270,000, have been found in red and blue-green algae; the red protein is called
phycoerythrin, the blue one phycocyanobilin. Phycocyanobilin consists of eight subunits with a
molecular weight of 28,000 each; about 89 percent of the molecule is protein with a large amount
of carbohydrate.
Evidence indicates that, in various animals, certain porphyrins may be involved in activating
hormones from the pituitary gland of the brain, including those concerned with the period of
sexual heat in certain female animals. Porphyrins in the integument (skin) of some mollusks and
cnidarians are regarded as being photosensitive receptors of light.
CHAPTER19
The kidneys are paired retroperitoneal structures that are normally located between the transverse
processes of T12-L3 vertebrae, with the left kidney typically somewhat more superior in position
than the right. The upper poles are normally oriented more medially and posteriorly than the
lower poles.
The kidneys serve important functions, including filtration and excretion of metabolic waste
products (urea and ammonium); regulation of necessary electrolytes, fluid, and acid-base
balance; and stimulation of red blood cell production. They also serve to regulate blood pressure
via the renin-angiotensin-aldosterone system, controlling reabsorption of water and maintaining

54

intravascular volume. The kidneys also reabsorb glucose and amino acids and have hormonal
functions via erythropoietin, calcitriol, and vitamin D activation.[1]
The kidney anatomy is shown in the image below.

Grossly, the kidneys are bean-shaped structures and weigh about 150 g in the male and about 135
g in the female. They are typically 10-12 cm in length, 5-7 cm in width, and 2-3 cm in thickness.
[2]

The relationship of neighboring organs to the kidneys is important, as described below:

Superiorly, the suprarenal (adrenal) glands sit adjacent to the upper pole of each kidney

On the right side, the second part of the duodenum (descending portion) abuts the medial
aspect of the kidney

On the left side, the greater curvature of the stomach can drape over the superomedial
aspect of the kidney, and the tail of the pancreas may extend to overlie the renal hilum

The spleen is located anterior to the upper pole and is connected by the splenorenal
(lienorenal) ligaments

Inferiorly to these organs, the colon typically rests anteriorly to the kidneys on both sides

55

Posteriorly, the diaphragm covers the upper third of each kidney, with the 12th rib most
commonly crossing the upper pole

The kidneys sit over the psoas (medially) and the quadratus lumborum muscles (laterally)

56

The images below further depict kidney anatomy and positioning

Renal anatomy, renal fascia.

arteries.

Intrarenal

Microanatomy of the nephron.

Vasculature

57

The kidneys receive approximately 20% of the cardiac output. The blood supply to the kidneys
arises from the paired renal arteries at the level of L2. They enter into the renal hilum, the
passageway into the kidney, with the renal vein anteriorly; the renal artery; and the renal pelvis
posteriorly.
The first branch off of the renal artery is the inferior suprarenal artery. The renal artery then
branches off into 5 segmental branches. The posterior segmental artery supplies most of the
posterior kidney, with the exception of the lower pole. The anterior branches are the superior
segmental artery, anterior superior segmental artery, anterior inferior segmental artery, and
inferior segmental artery. These arteries branch into interlobar arteries, which travel in a parallel
fashion in between the major calyces and then branch further into arcuate arteries that run within
the cortex across the bases of the renal pyramids.
They then radiate into interlobular arteries, which extend into the cortex of the kidney to finally
become afferent arterioles, then peritubular capillaries to efferent arterioles. Some of the terminal
branches of the interlobular arteries become perforating radiate arteries, which supply the renal
capsule. Renal pelvic and superior ureteric branches also originate from the renal artery and
supply the upper portion of the collecting system (see the image below).

Anatomy of collecting system.

58

The renal veins drain the kidneys in a similar distribution, and the renal vein is generally anterior
to the renal artery at the hilum. The left renal vein is longer than the right as it crosses the
midline to reach the inferior vena cava (IVC). Generally, the left gonadal vein drains into the left
renal vein inferiorly, while the left suprarenal vein drains into the superior aspect of the renal
vein at approximately the same level. Posteriorly, the left second lumbar vein typically drains
into the left renal vein as well. The left renal vein then crosses under the origin of the superior
mesenteric artery to reach the IVC. On the right side, the renal vein and gonadal vein drain
separately and directly into the IVC.
Renal lymphatics
The lymphatic drainage parallels the venous drainage system. After leaving the renal hilum, the
left primary lymphatic drainage is into the left lateral aortic lymph nodes, including nodes
anterior and posterior to the aorta between the inferior mesenteric artery and the diaphragm. On
the right, it drains into the right lateral caval lymph nodes.[3]
Collecting system
Once the filtrate gets to the collecting ducts in the medulla of the kidney, they converge to a renal
papilla, which represents the tip or apex of the renal pyramid. Urine then collects in typically 912 minor calyces, which then converge into 3-4 major calyces (significant variation is possible).
The major calyces then empty into the renal pelvis, which passes urine through the ureteropelvic
junction (UPJ) and into the ureter, which then propels urine distally to the bladder through
peristalsis. The ureter may course posterior to the renal artery (or a lower pole branch) at its
superior point, cross over the psoas muscle, and then pass posteriorly to the gonadal vessels. As
it proceeds further distally, it passes over the iliac vessels and into the pelvis, finally traversing
59

an intramural tunnel into the bladder and ending at the ureteral orifice on the trigone of the
bladder (see the image below).

Horseshoe kidney.
Renal nerve anatomy/autonomic innervation
The kidney receives autonomic supply via both the sympathetic and parasympathetic portions of
the nervous system. The preganglionic sympathetic nervous innervation to the kidneys arises
from the spinal cord at the level of T8-L1. They synapse onto the celiac and aorticorenal ganglia
and follow the plexus of nerves that run with the arteries. Activation of the sympathetic system
causes vasoconstriction of the renal vessels. Parasympathetic innervation arises from the 10th
cranial nerve (X), the vagus nerve, and causes vasodilation when stimulated.
CHAPTER20
Kidney Conditions

Pyelonephritis (infection of kidney pelvis): Bacteria may infect the kidney, usually
causing back pain and fever. A spread of bacteria from an untreated bladder infection is
the most common cause of pyelonephritis.

60

Glomerulonephritis: An overactive immune system may attack the kidney, causing


inflammation and some damage. Blood and protein in the urine are common problems
that occur with glomerulonephritis. It can also result in kidney failure.

Kidney stones (nephrolithiasis): Minerals in urine form crystals (stones), which may
grow large enough to block urine flow. It's considered one of the most painful conditions.
Most kidney stones pass on their own but some are too large and need to be treated.

Nephrotic syndrome: Damage to the kidneys causes them to spill large amounts of
protein into the urine. Leg swelling (edema) may be a symptom.

Polycystic kidney disease: A genetic condition resulting in large cysts in both kidneys
that impair their function.

Acute renal failure (kidney failure): A sudden worsening in kidney function. Dehydration,
a blockage in the urinary tract, or kidney damage can cause acute renal failure, which
may be reversible.

Chronic renal failure: A permanent partial loss of kidney function. Diabetes and high
blood pressure are the most common causes.

End stage renal disease (ESRD): Complete loss of kidney function, usually due to
progressive chronic kidney disease. People with ESRD require regular dialysis for
survival.

Papillary necrosis: Severe damage to the kidneys can cause chunks of kidney tissue to
break off internally and clog the kidneys. If untreated, the resulting damage can lead to
total kidney failure.
61

Diabetic nephropathy: High blood sugar from diabetes progressively damages the
kidneys, eventually causing chronic kidney disease. Protein in the urine (nephrotic
syndrome) may also result.

Hypertensive nephropathy: Kidney damage caused by high blood pressure. Chronic renal
failure may eventually result.

Kidney cancer: Renal cell carcinoma is the most common cancer affecting the kidney.
Smoking is the most common cause of kidney cancer.

Interstitial nephritis: Inflammation of the connective tissue inside the kidney, often
causing acute renal failure. Allergic reactions and drug side effects are the usual causes.

Minimal change disease: A form of nephrotic syndrome in which kidney cells look
almost normal under the microscope. The disease can cause significant leg swelling
(edema). Steroids are used to treat minimal change disease.

Nephrogenic diabetes insipidus: The kidneys lose the ability to concentrate the urine,
usually due to a drug reaction. Although it's rarely dangerous, diabetes insipidus causes
constant thirst and frequent urination.

Renal cyst: A benign hollowed-out space in the kidney. Isolated kidney cysts occur in
many normal people and almost never impair kidney function.

Kidney Tests

Urinalysis: A routine test of the urine by a machine and often by a person looking through
a microscope. Urinalysis can help detect infections, inflammation, microscopic bleeding,
and kidney damage.
62

Kidney ultrasound: A probe placed on the skin reflects sound waves off the kidneys,
creating images on a screen. Ultrasound can reveal blockages in urine flow, stones, cysts,
or suspicious masses in the kidneys.

Computed tomography (CT scan): A CT scanner takes a series of X-rays and a computer
creates detailed images of the kidneys.

Magnetic resonance imaging (MRI scan): A scanner uses radio waves in a magnetic field
to make high-resolution images of the kidneys.

Urine and blood cultures: If an infection is suspected, cultures of the blood and urine may
identify the bacteria responsible. This can help target antibiotic therapy.

Ureteroscopy: An endoscope (flexible tube with a camera on its end) is passed through
the urethra into the bladder and ureters. Ureteroscopy generally cannot reach the kidneys
themselves, but can help treat conditions that also affect the ureters.

Kidney biopsy: Using a needle inserted into the back, a small piece of kidney tissue is
removed. Examining the kidney tissue under a microscope may help diagnose a kidney
problem.

Kidney Treatments

Antibiotics: Kidney infections caused by bacteria are treated with antibiotics. Often,
cultures of the blood or urine can help guide the choice of antibiotic therapy.

Nephrostomy: A tube (catheter) is placed through the skin into the kidney. Urine then
drains directly from the kidney, bypassing any blockages in urine flow.

63

Lithotripsy: Some kidney stones may be shattered into small pieces that can pass in the
urine. Most often, lithotripsy is done by a machine that projects ultrasound shock waves
through the body.

Nephrectomy: Surgery to remove a kidney. Nephrectomy is performed for kidney cancer


or severe kidney damage.

Dialysis: Artificial filtering of the blood to replace the lost function of damaged kidneys.
Hemodialysis is the most common method of dialysis in the U.S.

Hemodialysis: A person with complete kidney failure is connected to a dialysis machine,


which filters the blood and returns it to the body. Hemodialysis is typically done three
days per week in people with ESRD.

Peritoneal dialysis: Placing large amounts of a special fluid in the abdomen through a
catheter, allows the body to filter the blood using the natural membrane lining the
abdomen. After a while the fluid with the waste is drained and discarded.

Kidney transplant: Transplanting a kidney into a person with ESRD can restore kidney
function. A kidney may be transplanted from a living donor, or a recently deceased organ
donor.

CHAPTER21
Electrolytes are the smallest of chemicals that are important for the cells in the body to function
and allow the body to work. Electrolytes such as sodium, potassium, and others are critical in
allowing cells to generate energy, maintain the stability of their walls, and to function in general.

64

They generate electricity, contract muscles, move water and fluids within the body, and
participate in myriad other activities.

The concentration of electrolytes in the body is controlled by a variety of hormones, most of


which are manufactured in the kidney and the adrenal glands. Sensors in specialized kidney cells
monitor the amount of sodium, potassium, and water in the bloodstream. The body functions in a
very narrow range of normal, and it is hormones like renin (made in the kidney), angiotensin
(from the lung, brain and heart), aldosterone (from the adrenal gland), and antidiuretic hormone
(from the pituitary) that keep the electrolyte balance within those normal limits.
Electrolytes are minerals in your blood and other body fluids that carry an electric charge.

Electrolytes affect the amount of water in your body, the acidity of your blood (pH), your muscle
function, and other important processes. You lose electrolytes when you sweat. You must replace
them by drinking fluids that contain electrolytes. Water does not contain electrolytes.
Common electrolytes include:

Calcium
Chloride
Magnesium

65

Phosphorous
Potassium
Sodium
Electrolytes can be acids, bases, and salts.
They can be measured by laboratory studies of the blood in different ways. Each electrolyte can
be ordered as a separate test, such as:

Ionized calcium
Serum calcium
Serum chloride
Serum magnesium
Serum phosphorus
Serum potassium
Serum sodium
Note: Serum is the part of blood that doesn't contain cells.

Sodium, potassium, and chloride can also be ordered as part of an electrolyte panel, a basic
metabolic panel or a comprehensive metabolic panel.
66

The electrolytes - urine test measures electrolytes in urine. It usually measures the levels of
calcium, chloride, potassium, or sodium.
CHAPTER22
n important property of blood is its degree of acidity or alkalinity. Blood acidity increases when
the level of acidic compounds in the body rises (through increased intake or production, or
decreased elimination) or when the level of basic (alkaline) compounds in the body falls (through
decreased intake or production, or increased elimination). Blood alkalinity increases with the
reverse processes. The body's balance between acidity and alkalinity is referred to as acid-base
balance. The acidity or alkalinity of any solution, including blood, is indicated on the pH scale.
The blood's acid-base balance is precisely controlled because even a minor deviation from the
normal range can severely affect many organs. The body uses different mechanisms to control
the blood's acid-base balance.
Role of the lungs:
One mechanism the body uses to control blood pH involves the release of carbon dioxide from
the lungs. Carbon dioxide, which is mildly acidic, is a waste product of the metabolism of
oxygen (which all cells need) and, as such, is constantly produced by cells. As with all waste
products, carbon dioxide gets excreted into the blood. The blood carries carbon dioxide to the
lungs, where it is exhaled. As carbon dioxide accumulates in the blood, the pH of the blood
decreases (acidity increases). The brain regulates the amount of carbon dioxide that is exhaled by
controlling the speed and depth of breathing. The amount of carbon dioxide exhaled, and

67

consequently the pH of the blood, increases as breathing becomes faster and deeper. By adjusting
the speed and depth of breathing, the brain and lungs are able to regulate the blood pH minute by
minute.
Role of the kidneys:
The kidneys are able to affect blood pH by excreting excess acids or bases. The kidneys have
some ability to alter the amount of acid or base that is excreted, but because the kidneys make
these adjustments more slowly than the lungs do, this compensation generally takes several days.
Buffer systems:
Yet another mechanism for controlling blood pH involves the use of buffer systems, which guard
against sudden shifts in acidity and alkalinity. The pH buffer systems are combinations of the
body's own naturally occurring weak acids and weak bases. These weak acids and bases exist in
pairs that are in balance under normal pH conditions. The pH buffer systems work chemically to
minimize changes in the pH of a solution by adjusting the proportion of acid and base. The most
important pH buffer system in the blood involves carbonic acid (a weak acid formed from the
carbon dioxide dissolved in blood) and bicarbonate ions (the corresponding weak base).
Acidosis and alkalosis:
There are two abnormalities of acid-base balance.
Acidosis: The blood has too much acid (or too little base), resulting in a decrease in blood

pH.

Alkalosis: The blood has too much base (or too little acid), resulting in an increase in
blood pH.
68

Acidosis and alkalosis are not diseases but rather are the result of a wide variety of disorders.
The presence of acidosis or alkalosis provides an important clue to doctors that a serious problem
exists.
Acidosis and alkalosis are categorized as metabolic or respiratory, depending on their primary
cause. Metabolic acidosis and metabolic alkalosis are caused by an imbalance in the production
of acids or bases and their excretion by the kidneys. Respiratory acidosis and respiratory
alkalosis are caused primarily by changes in carbon dioxide exhalation due to lung or breathing
disorders.
CHAPTER23
Therapeutic drug monitoring (TDM) is the clinical practice of measuring specific drugs at
designated intervals to maintain a constant concentration in a patient's bloodstream, thereby
optimizing individual dosage regimens. It is unnecessary to employ TDM for the majority of
medications, and it is used mainly for monitoring drugs with narrow therapeutic ranges, drugs
with marked pharmacokinetic variability, medications for which target concentrations are
difficult to monitor, and drugs known to cause therapeutic and adverse effects. The process of
TDM is predicated on the assumption that there is a definable relationship between dose and
plasma or blood drug concentration, and between concentration and therapeutic effects. TDM
begins when the drug is first prescribed, and involves determining an initial dosage regimen
appropriate for the clinical condition and such patient characteristics as age, weight, organ
function, and concomitant drug therapy. When interpreting concentration measurements, factors
that need to be considered include the sampling time in relation to drug dose, dosage history,
patient response, and the desired medicinal targets. The goal of TDM is to use appropriate
69

concentrations of difficult-to-manage medications to optimize clinical outcomes in patients in


various clinical situations.
As stated previously, the practice of therapeutic drug monitoring requires the orchestration of
several disciplines, including pharmacokinetics, pharmacodynamics, and laboratory analysis.
The analytical impact on determining pharmacokinetic parameters is not well appreciated.
Analytical goals in therapeutic drug monitoring should be established by determining the nature
of the problem to be solved, selecting the appropriate matrix and methodology to solve the
problem, and developing valid analytical schemes that are performed competently with
appropriate quality and interpreted within the framework of the problem.
CHAPTER24
Toxicology is the study of the adverse effects of chemicals on living organisms. It is the study of
symptoms, mechanisms, treatments and detection of poisoning, especially the poisoning of
people.
The relationship between dose and its effects on the exposed organism is of high significance in
toxicology. The chief criterion regarding the toxicity of a chemical is the dose, i.e. the amount of
exposure to the substance.
All substances are toxic under the right conditions. The term LD50 refers to the dose of a toxic
substance that kills 50 percent of a test population (typically rats or other surrogates when the
test concerns human toxicity).
LD50 estimations in animals are no longer required for regulatory submissions as a part of preclinical development package.
70

The conventional relationship (more exposure equals higher risk) has been challenged in the
study of endocrine disruptors.
There are various specialized subdisciplines within the field of toxicology that concern diverse
chemical and biological aspects of this area.
For example, toxicogenomics involves applying molecular profiling approaches to the study of
toxicology.
Other areas include Aquatic toxicology, Chemical toxicology, Ecotoxicology, Environmental
toxicology, Forensic toxicology, and Medical toxicology.
Chemical toxicology is a scientific discipline involving the study of structure and mechanism
related to the toxic effects of chemical agents, and encompasses technology advances in research
related to chemical aspects of toxicology.
Research in this area is strongly multidisciplinary, spanning computational chemistry and
synthetic chemistry, proteomics and metabolomics, drug discovery, drug metabolism and
mechanisms of action, bioinformatics, bioanalytical chemistry, chemical biology, and molecular
epidemiology.

CHAPTER25
Hormones are peptides/proteins, lipids or aminoacid derivatives which after their secretion act on
receptors to cause reactions within the respective receptive cells. Each cell of the body is in one

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way or another regulated by hormones. Hence, hormones exert innumerable effects on the
organism of animals and humans.
These multiple effects can be adversely deregulated by Endocrine Disrupting chemicals, (EDs),
which are taken up through food or drinks or through the air. Occasionally, they are also
absorbed transdermally. This topic has been dealt with in an Endocrine Society scientific
statement.1 EDs are mainly unintentionally taken but there are also examples of intentional
intake of substances possessing putative ED properties.
Basically, hormones vitally modify three biological processes: they are essential for
reproduction, for optimal survival and for normal biological performance. Hence, they are
essential for the maintenance of species and for coping with daily environmental influences.
Most EDs may interact with the effects of lipid (steroid) or aminoacid derived (thyroid)
hormones, while a few interact with peptide/protein hormone synthesis or signalling. However,
effects of EDs through steroid receptors on peptide/protein hormones are common.
Hormones can be classified by various means, including by their structure and function.
Traditionally there are three classifications of hormones:
Classical Hormones: secreted from endocrine cells directly into interstitial fluid. These diffuse
into the bloodstream to be distributed to all parts of the body served by the circulatory system.
Neurohormones: synthesized in neuroendocrine cells and secreted from nerve terminals. These
diffuse into blood vessels for transportation around the body.
Local Hormones: these are secreted into the interstitial fluid and act locally, on neighbouring
cells (paracrine action) or on the cell which secreted them (autocrine action).
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Additionally, hormones can be classified by their structure:


Amino Acid Derivatives: these are derived from the amino acid Tyrosine. Examples include
Catecholamines and Thyroid Hormones.
Fatty Acid Compounds: these are derived from a polyunsaturated fatty acid pre-cursor, usually
arachidonic acid. Hormones with this structure form the group Eicosenoids, and are important in
imflammatory processes.
Peptide Hormones: these vary from small peptides to long chain proteins. They are synthesized
via transcription and translation pathways within cells, and may be derived from prohormones.
They are secreted out of the endocrine cell by exocytosis. Examples include Insulin.
Steroid Hormones: these lipid soluble hormones are derived from cholesterol. They are
synthesised and secreted as needed; there is no capacity for storage. Examples include Cortisol,
Androgens and Calcitriol.
CHAPTER26
The hypothalamus is a small area in the ventral diencephalon of the forebrain, in the floor of the
third ventricle, and is a functional link between the nervous and endocrine systems.
The hypothalamus controls most of the endocrine glands within the body, largely through
stimulation of the Pituitary Gland by secretion of neurohormones. It is a vital regulator of
homeostasis, including Thermoregulation.
The hypothalamus recieves direct inputs via specific receptors. It also recieves indirect inputs
from the blood and nerves.

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Direct Inputs via Receptors:


Thermoreceptors: Neurons in the anterior hypothalamus respond to heat by initiating peripheral
vasodilation and sweating. Neurons in the posterior hypothalamus respond to cold by initiating
shivering, piloerection and peripheral vasoconstriction. These mechanisms are part of the
Thermoregulation system.
Osmoreceptors: respond to an increase in blood osmolarity by releasing Antidiuretic Hormone
(ADH) from the Supraoptic Nucleus which is then secreted by the posterior pituitary and acts to
retain water at the kidneys. It also stimulates neurons in the thirst centre in the lateral
hypothalamus in an attempt to increase water intake.
Energy Balance: Neurons in the arcuate nucleus sense blood glucose and hormones. Leptin
causes satiety, ghrelin stimulates appetite.
Indirect Inputs from bloodstream include information about:
Temperature
Osmotic Pressure
Hormone concentrations - including Leptin, Cortisol, Oestrogens, Progesterone, Androgens, T3.
Indirect Neural Inputs:
Uses Visceral and somatic sensory neurons, the Limbic System and the Reticular Activating
System.
Outputs

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Biological Clock - Light sensed by retina causes stimulation of neurons leading the the
suprachiasmatic nucleus which stimulates the Pineal Gland as a result.
Secretory Neurons - ADH and Oxytocin are released by the Supraoptic and Paraventricular
nuclei cell bodies. The axons descend into the Posterior Pituitary gland, where they terminate in
blood vessels releasing the hormone directly into circulation. Thus the posterior pituitary acts as
a storage site and is not a true endocrine gland.
Hypothalamic Hormones - the hypothalamus releases hormones which have an activating or
inhibitory effect on their target organ, hence they are named Releasing or Inhibitory Hormones
respectively.
Releasing Hormones:
Thyrotropin Releasing Hormone (TRH)
Growth Hormone Releasing Hormone (GH-RH)
Gonadotrophin Releasing Hormone (GnRH)
Corticotropin Releasing Hormone (CRH)
Prolactin Releasing Hormone (PRL-RH)
Inhibitory Hormones:
Growth Hormone Inhibiting Hormone aka Somatostatin (GH-IH)
Gonadotrophin Inhibiting Hormone (GnIH)
Dopamine (PRL-IH)
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CHAPTER27
Thyroid hormones are extremely important and have diverse actions. They act on virtually every
cell in the body to alter gene transcription: under- or over-production of these hormones has
potent effects. Disorders associated with altered thyroid hormone secretion are common and
affect about 5% women and 0.5% men.
Like the catecholamines epinephrine and norepinephrine, thyroid hormones are synthesized from
the amino acid tyrosine. The synthesis of thyroid hormones requires the iodination of tyrosine
molecules and the combination of two iodinated tyrosine residues (Box 3.1). Whilst tyrosine is
relatively easily iodinated, iodine is rare, ranking 61st in the list of most common elements and
forming just 0.000006% of the Earth's mantle. The thyroid gland has evolved not only to trap this
element avidly from dietary sources but also to maintain a large store of the iodinated tyrosines
to maintain the secretion of thyroid hormones during periods of relative iodine deficiency.
CHAPTER28
Thyroid Essentials

The thyroid regulates your metabolism.

The two main thyroid hormones are T3 and T4.

Thyroid disorders are common, and they include goiters, hyperthyroidism, and
hypothyroidism.

The thyroids main role in the endocrine system is to regulate your metabolism, which is your
bodys ability to break down food and convert it to energy. Food essentially fuels our bodies, and

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our bodies each burn that fuel at different rates. This is why you often hear about some people
having fast metabolism and others having slow metabolism.

The thyroid keeps your metabolism under control through the action of thyroid hormone, which
it makes by extracting iodine from the blood and incorporating it into thyroid hormones. Thyroid
cells are unique in that they are highly specialized to absorb and use iodine. Every other cell
depends on the thyroid to manage its metabolism.

The pituitary gland and hypothalamus both control the thyroid. When thyroid hormone levels
drop too low, the hypothalamus secretes TSH Releasing Hormone (TRH), which alerts the
pituitary to produce thyroid stimulating hormone (TSH). The thyroid responds to this chain of
events by producing more hormones. To learn more, read our article about how the thyroid
works.

Anatomy of the Thyroid

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Derived from the Greek word meaning shield, the thyroid is a butterfly-shaped gland located in
front of the windpipe (called the trachea) and just below the larynx or Adams apple in the neck.
It is comprised of two halves, known as lobes, which are attached by a band of thyroid tissue
called the isthmus.

During development, the thyroid is actually located in the back of the tongue and has to migrate
to the front of the neck before birth. There are rare instances when the thyroid migrates too far or
too little. There are even cases when the thyroid remains in the back of the tonguethis is
known as lingual thyroid.

Hormones of the Thyroid


The two main hormones the thyroid produces and releases are T3 (tri-iodothyronine) and T4
(thyroxine). A thyroid that is functioning normally produces approximately 80% T4 and about
20% T3, though T3 is the stronger of the pair.

To a lesser extent, the thyroid also produces calcitonin, which helps control blood calcium levels.

Diseases and Disorders of the Thyroid


There are many diseases and disorders associated with the thyroid. They can develop at any age
and can result from a variety of causesinjury, disease, or dietary deficiency, for instance. But in
most cases, they can be traced to the following problems:

Too much or too little thyroid hormone (hyperthyroidism and hypothyroidism,


respectively).

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Abnormal thyroid growth

Nodules or lumps within the thyroid

Thyroid cancer

Below are some of the most common thyroid disorders. To learn more, read our article
about common thyroid problems.

Goiters: A goiter is a bulge in the neck. A toxic goiter is associated with


hyperthyroidism, and a non-toxic goiter, also known as a simple or endemic goiter, is caused by
iodine deficiency.

Hyperthyroidism: Hyperthyroidism is caused by too much thyroid hormone. People


with hyperthyroidism are often sensitive to heat, hyperactive, and eat excessively. Goiter is
sometimes a side effect of hyperthyroidism. This is due to an over-stimulated thyroid and
inflamed tissues, respectively.

Hypothyroidism: Hypothyroidism is a common condition characterized by too little


thyroid hormone. In infants, the condition is known as cretinism. Cretinism has very serious side
effects, including abnormal bone formation and mental retardation. If you have hypothyroidism
as an adult, you may experience sensitivity to cold, little appetite, and an overall sluggishness.
Hypothyroidism often goes unnoticed, sometimes for years, before being diagnosed.

Solitary thyroid nodules: Solitary nodules, or lumps, in the thyroid are actually quite
commonin fact, its estimated that more than half the population will have a nodule in their
thyroid. The great majority of nodules are benign.

Thyroid cancer: Thyroid cancer is fairly common, though the long-term survival rates
are excellent. Occasionally, symptoms such as hoarseness, neck pain, and enlarged lymph nodes
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occur in people with thyroid cancer. Thyroid cancer can affect anyone at any age, though women
and people over thirty are most likely to develop the condition.
Thyroiditis: Thyroiditis is an inflammation of the thyroid that may be associated with

abnormal thyroid function (particularly hyperthyroidism). Inflammation can cause the thyroids
cells to die, making the thyroid unable to produce enough hormones to maintain the body's
normal metabolism. There are five types of thyroiditis, and the treatment is specific to each.

CHAPTER29
The adrenal glands are two glands that sit on top of your kidneys that are made up of two distinct
parts.

The adrenal cortexthe outer part of the glandproduces hormones that are vital to life,
such as cortisol (which helps regulate metabolism and helps your body respond to stress) and
aldosterone (which helps control blood pressure).

The adrenal medullathe inner part of the glandproduces nonessential (that is, you
dont need them to live) hormones, such as adrenaline (which helps your body react to stress).

When you think of the adrenal glands (also known as suprarenal glands), stress might come to
mind. And rightly sothe adrenal glands are arguably best known for secreting the hormone
adrenaline, which rapidly prepares your body to spring into action in a stressful situation.

But the adrenal glands contribute to your health even at times when your body isnt under
extreme stress. In fact, they release hormones that are essential for you to live.
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Anatomy of the Adrenal Glands


The adrenal glands are two, triangular-shaped organs that measure about 1.5 inches in height and
3 inches in length. They are located on top of each kidney. Their name directly relates to their
location (adnear or at; reneskidneys).

Each adrenal gland is comprised of two distinct structuresthe outer part of the adrenal glands
is called the adrenal cortex. The inner region is known as the adrenal medulla.

Hormones of the Adrenal Glands


The adrenal cortex and the adrenal medulla have very different functions. One of the main
distinctions between them is that the hormones released by the adrenal cortex are necessary for
life; those secreted by the adrenal medulla are not.

Adrenal Cortex Hormones


The adrenal cortex produces two main groups of corticosteroid hormonesglucocorticoids and
mineralcorticoids. The release of glucocorticoids is triggered by the hypothalamus and pituitary
gland. Mineralcorticoids are mediated by signals triggered by the kidney.

When the hypothalamus produces corticotrophin-releasing hormone (CRH), it stimulates the


pituitary gland to release adrenal corticotrophic hormone (ACTH). These hormones, in turn, alert
the adrenal glands to produce corticosteroid hormones.

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Glucocorticoids released by the adrenal cortex include:

Hydrocortisone: Commonly known as cortisol, it regulates how the body converts fats,
proteins, and carbohydrates to energy. It also helps regulate blood pressure and cardiovascular
function.

Corticosterone: This hormone works with hydrocortisone to regulate immune response


and suppress inflammatory reactions.

The principle mineralcorticoid is aldosterone, which maintains the right balance of salt and
water while helping control blood pressure.

There is a third class of hormone released by the adrenal cortex, known as sex steroids or sex
hormones. The adrenal cortex releases small amounts of male and female sex hormones.
However, their impact is usually overshadowed by the greater amounts of hormones (such as
estrogen and testosterone) released by the ovaries or testes.

Adrenal Medulla Hormones


Unlike the adrenal cortex, the adrenal medulla does not perform any vital functions. That is, you
dont need it to live. But that hardly means the adrenal medulla is useless. The hormones of the
adrenal medulla are released after the sympathetic nervous system is stimulated, which occurs
when youre stressed. As such, the adrenal medulla helps you deal with physical and emotional
stress. You can learn more by reading a SpineUniverse article about the sympathetic nervous
system.

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You may be familiar with the fight-or-flight responsea process initiated by the sympathetic
nervous system when your body encounters a threatening (stressful) situation. The hormones of
the adrenal medulla contribute to this response.

Hormones secreted by the adrenal medulla are:

Epinephrine: Most people know epinephrine by its other nameadrenaline. This


hormone rapidly responds to stress by increasing your heart rate and rushing blood to the
muscles and brain. It also spikes your blood sugar level by helping convert glycogen to glucose
in the liver. (Glycogen is the livers storage form of glucose.)

Norepinephrine: Also known as noradrenaline, this hormone works with epinephrine in


responding to stress. However, it can cause vasoconstriction (the narrowing of blood vessels).
This results in high blood pressure.

Disorders and Diseases of the Adrenal Glands


There are multiple reasons why the adrenal glands might not work as they should. The problem
could be with the adrenal gland itself, or the root cause may be due to a defect in another gland.

Below are the most common disorders and diseases of the adrenal glands:

Addisons disease: This rare disorder may affect anyone at any age. It develops when the
adrenal cortex fails to produce enough cortisol and aldosterone. To learn more, read our article
about Addison's Disease.

Adrenal cancer: Adrenal cancer is an aggressive cancer, but its very rare. Malignant
adrenal tumors are rarely confined to the adrenal glandsthey tend to spread to other organs and

83

cause adverse changes within the body because of the excess hormones they produce. To learn
more, read our article about adrenal cancer.

Cushings syndrome: Cushings syndrome is an uncommon condition that is essentially


the opposite of Addisons disease. It is caused by overproduction of the hormone cortisol. There
are a variety of causes of this disordera tumor in the adrenal gland or pituitary gland could be
to blame. To learn more, read our article about Cushing's syndrome.

Congenital adrenal hyperplasia: This genetic disorder is characterized by low levels of


cortisol. Its common for people with congenital adrenal hyperplasia to have additional hormone
problems such as low levels of aldosterone (which maintains a balance of water and salt).
The adrenal glands have a multi-functional role in the endocrine system. The two very different
parts of these glands, the medulla and cortex, regulate and maintain many of your internal
processesfrom metabolism to the fight-or-flight response.

CHAPTER30

CHAPTER31
Reproductive Endocrinology is a sub-specialty of Obstetrics and Gynecology. This requires 4
years of medical school followed by completion of a 4 year residency in Obstetrics and
Gynecology. Training includes:

Medical and surgical treatment of disorders of the female reproductive tract

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Care of pregnant women


Delivering babies
After completing a residency program, a physician would apply through a highly competitive
system to receive additional training in Reproductive Endocrinology. This is referred to as a
fellowship and includes a 3 year intensive training program, which focuses on understanding the
complexities of the human female reproductive system.

Reproductive Endocrinologists receive board certification by the American Board of Obstetrics


and Gynecology in both Obstetrics and Gynecology and Reproductive Endocrinology and
Infertility. These require both written and oral examinations.

CHAPTER32

CHAPTER33
CHAPTER34
CHAPTER35
CHAPTER36
CHAPTER37
CHAPTER38
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