LABORATORY DIAGNOSIS

2A LIVER FUNCTION TESTS

L-08 Dr. Mila Am or Reyes | A.Y. 2018 -2019

Topic Outline GILBERT'S SYNDROME- most common cause of

unconjugated hyperbilirubinemia (elevated levels in the
I. Excretion of bile pigments bloodstream)
II. Hepatic synthetic function
III. Enzyme Tests Used to Established the Presence of  In the neonates, prolonged unconjugated
Hepatocellular Damage hyperbilirubinemia should be carefully followed up to
IV. Serum Serologic Studies prevent kernicterus (CNS damage due to high levels of
V. Serum Protein Markers B1).

TEST FOR LIVER FUNCTION BASED ON:

EXCRETION OF BILE PIGMENTS
BILIRUBIN
 Degradation product of heme
 Derived from senescent RBCs
 Bound to albumin and transported to the liver for
conjugation with glucoronic acid and excreted into the bile
 Defects in one of the steps or increased heme breakdown
can lead to increased serum levels

TESTS USED TO DETERMINE BILIRUBIN

 DIAZO REACTION- most commonly used method
to measure serum bilirubin levels
 Distinguishes 2 bilirubin fractions- indirect and direct
 Direct Bilirubin (B2, conjugated)- reacted immediately
with Ehrlich's diazo reagent (diazotized sulfanilic acid).
 Total bilirubin- reacted after the addition of alcohol to the
reaction mixture.
CONJUGATED HYPERBILIRUBINEMIA
 B1 (Indirect, unconjugated)= Total bilirubin – B2
 Caused by impaired secretion into the bile or by bile duct
 Light causes bilirubin to breakdown (oxidation)
obstruction (intrahepatic or extrahepatic).
 Falsely low values may be obtained on serum samples
 CHOLESTASIS- decreased bile flow (from the
exposed to light for prolonged periods
hepatocyte to the ampulla of Vater); produces the
 NV:
highest levels of serum bilirubin
o 0.2 to 1.0 mg/dL (total bilirubin)
 NEONATAL CONJUGATED HYPERBILIRUBINEMIA-
o 0.0 to 0.2 mg/dL (direct bilirubin)
extrahepatic bile duct atresia
o 0.0 to 0.8 mg/dL (indirect bilirubin)

 HIGH-PERFORMANCE LIQUID CHROMATOGRAPHY

(HPLC)- used for quantifying serum bilirubin, distinguishes
4 fractions (α,β, δ, γ)
o α—unconjugated
o β—monoconjugated
o δ—diconjugated
o γ—covalently bound to albumin

 Classic clinical manifestation of liver disease is

JAUNDICE or ICTERUS (nonspecific finding)
 Jaundice or icterus can be detected clinically
when the total bilirubin level rises >2 to 3 mg/dL

UNCONJUGATED HYPERBILIRUBINEMIA
 Occurs when serum B1 is >1.2 mg/dL and <20% of the
total bilirubin consists of B2
 Causes:
o Hemolytic disorders
o Defective hemoglobin formation
o Impaired hepatic uptake or conjugation of
bilirubin

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 L-08 LIVER FUNCTION TESTS
URINE BILIRUBIN
 B1 is nonfilterable by the glomerulus, and do not  NORMAL SERUM ALBUMIN:
appear in urine. o Acute viral hepatitis
 B2 is water soluble, can be filtered by the glomerulus, o Drug-related hepatotoxicity
and can be detected in urine. o Obstructive jaundice
 Absence of bilirubinuria in the presence of jaundice  HYPOALBUMINEMIA:
implies unconjugated hyperbilirubinemia. o Ascites (dilution)
 False(+) dipstick test can occur in urine: o Chronic inflammatory processes
o From women with UTI who are taking o Protein-losing enteropathies
phenazopyridine HCI or phenothiazine-containing o Nephrotic Syndrome
drugs o Malnutrition
 False(-) dipstick test can occur in urine:
o In specimens left standing (delay in U/A) due to ENZYME TESTS USED TO ESTABLISH THE PRESENCE
photooxidation and hydrolysis of urinary bilirubin OF HEPATOCELLULAR DAMAGE
ASPARTATE AND ALANINE AMINOTRANSFERASE
TEST FOR HEPATIC SYNTHETIC FUNCTION  Used as sensitive indicators of hepatocellular injury
PROTHROMBIN TIME  NV: 5 to 40 U/L
 Measures the time (seconds) required for a patient's
citrated plasma to cause the formation of fibrin clot by ASPARTATE AMINOTRANSFERASE (AST/SGOT)
converting prothrombin (synthesized in the liver) to  Present in Liver, Heart, Skeletal muscle, Brain, Kidneys
thrombin, and subsequently thrombin catalyzes the  Within liver:
polymerization of fibrinogen to fibrin. o 80% is found in the mitochondria
 NV: 12 to 15 seconds o 20% in cytoplasm
 PT is influenced by the quality and quantity of CFs (i.e., I,  Alcohol is a mitochondrial toxin:
II, V, VII, X) synthesized in the liver (EXTRINSIC o Serum AST/ALT ratio (De Ritis quotient), if >2.0
PATHWAY) suggestive of Alcoholic Liver Disease
 PROLONGED PT is usually caused by:
o Medications that inhibit CFs (II, VII, IX,X) ALANINE AMINOTRANSFERASE (ALT/SGPT)
o Congenital deficiency of CFs  Only small amounts are found in tissues other than
o Vitamin K deficiency due to obstructive the liver
jaundice, steatorrhea, or antibiotics that alter  More specific indicator of hepatocyte injury
the intestinal flora that produce Vitamin K or  Almost all located within cytoplasm
inhibit the intrahepatic recycling of vitamin K  If serum ALT level is high, regardless of the magnitude
o Inadequate utilization of Vitamin K due to liver of the AST/ALT ratio, acute or chronic hepatitis (viral or
dysfunction (can be differentiated from: drug-induced) or a cholestatic process is more likely.
 Vit. K deficiency by parenteral
administration of Vit. K to the patient;
 Correction of the PT indicates Vit. K
deficiency, while in patients with liver
disease, the PT remains prolonged)
 PT test is NOT a sensitive test for liver disease (may
be normal in patients with cirrhosis)
 PT is useful in the following situations:
o Follow-up of patients with acute liver injury due
to:
 Acute viral hepatitis
 Alcoholic steatonecrosis
 Acetaminophen toxicity
o PT result >4 to 5 secs above the ULN (upper
limit of normal) that is NOT responsive to Vitamin
K therapy indicates extensive hepatic damage
and poor long-term prognosis.
o Screening test for estimating the likelihood of
intraoperative or perioperative bleeding
problems in patients undergoing surgical
procedure.
ALKALINE PHOSPHATASE (ALP)
ALBUMIN LEVEL
 Present in Bone, Liver, Leukocytes, Intestine, Placenta
 Main osmotic colloid of plasma, synthesized exclusively by
 Principal ALP isoenzyme found in serum from healthy
the liver
persons is derived from the BONE
 NV: 3.5 to 5.6 g/dL (35-45 g/L)

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 L-08 LIVER FUNCTION TESTS
 Increased in serum ALP concentration: GAMMA-GLUTAMYLTRANSFERASE (GGT)
o Children  Increased serum concentration of GGT is NOT due to
o Puberty hepatocyte damage but secondary to increased
o Pregnant women enzyme production (like ALP)
o Liver or Bone disease o Alcohol ingestion is one of the more common
 Increased serum concentration of ALP is NOT due to causes of an increased serum GGT level, also,
hepatocyte damage but results from increased synthesis drugs (phenytoin and acetaminophen)
of hepatic ALP. • Used as screening tool for identifying
 Stimulus for increased ALP production: alcoholics, as well as during treatment and
o Bile duct obstruction follow-up of alcoholic patients
o Intrahepatically by infiltrative or space-
occupying lesions (i.e., metastases)
o Extrahepatically by stones, stricture, or tumor SERUM SEROLOGIC STUDIES
 Serum ALP concentration- sensitive indicator of HEPATITIS B SURFACE ANTIGEN
intrahepatic or extrahepatic cholestasis:  Those who clear the virus and develop immunity, HBsAg
o Markedly increased ALP levels suggest becomes undetectable and replaced by anti-HBs.
Obstruction  Persistence of HBsAg in the serum for >6 months
o Modestly increased levels suggest indicates chronic carrier state, which may or may not be
Hepatocellular injury associated with active hepatitis.
 Long-term carrier state for HBV is a risk factor for the
development of hepatocellular CA.

HEPATITIS B ENVELOPE ANTIGEN AND HBV DNA

 HBeAg appears in the serum shortly after HBsAg in acute
HBV infections.
 Presence of HBeAg indicates:
o High level of viral replication, and;
o Risk factor for active liver disease and
increased infectivity
 Active viral replication and risk for infectivity can be
obtained by analyzing serum for the presence of HBV
DNA by PCR or hybridization techniques.

 In CHRONIC HEPATITIS, if HBsAg is (+), then,

subsequent testing for HBeAg or HBV DNA is appropriate
to document the presence or absence of active viral
replication and to assess the risk of infectivity.

HEPATITIS B CORE ANTIGEN

 HBcAg is NOT detectable in serum by routine techniques
in acute or chronic HBV infection
 Increased serum ALP levels can also be due to bone  Detectable in liver tissue by immunoperoxidase staining
disease:  May be the most analytically sensitive method for
o To confirm the origin of ALP is to measure the detecting active viral replication in chronic HBV
serum level of GGT (liver-associated, infection.
microsomal enzyme not found in bone)
o Increased serum levels of GGT and ALP strongly ANTIBODY TO HBs
suggest that the ALP originated from the liver  Anti-HBs develops in those who recover from acute HBV
o Alternatively, serum can be heated at 56°C for
infection
10 mins, to inactivate more of the bone than liver
 Failure to develop anti-HBs by 6 months after infection is
ALP, and re-assayed for ALP concentration
characteristic of the chronic carrier state, associated with
 If <20% of the initial serum ALP level
(+) HBsAg
remains, the ALP
 Anti-HBs provides immunity to subsequent exposures to
present is largely of the bone type,
HBV, but antibody may disappear leaving anti-HBc as
residual activities of
the only marker indicative of previous infection
25%-55% require electrophoresis
 HBV vaccines result in anti-HBs positivity without the
concomitant presence of anti-HBc

ANTIBODY TO HBe
 Anti-HBe becomes detectable in serum when HBeAg has
been cleared (like anti-HBs), and generally indicates
resolution of acute infection
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 L-08 LIVER FUNCTION TESTS
ANTIBODY TO HBc
 Initial Antibody produced:
o IgM anti-HBc indicates recent HBV infection;
o Replaced by IgG which is detectable in serum for
life
 Early in acute HBV infection, when HBsAg has
disappeared but anti-HBs has not yet reached detectable
levels (window period), the presence of IgM anti-HBc
may be the only clue to the presence of infection.
ANTIBODY TO HEPATITIS C AND RNA DETECTION
 HCV is responsible for most parenterally transmitted
cases of non-A, non-B hepatitis
 Laboratory tests for detecting HCV infection:
o 1. First-generation EIAs- screening test,
lacked sensitivity and specificity
 Autoimmune chronic active hepatitis and
alcoholic liver disease caused False(+)
results
o 2. Second-generation EIAs- increased
sensitivity and detect Ab earlier (6 weeks after
onset); low specificity
o 3. Recombinant Immunoblot Assay (RIBA)-
more sensitive and more specific
 Detection of HCV RNA by the PCR (Polymerase Chain
Reaction) is well correlated with HCV transmission.
 If anti-HCV is (–) and index of suspicion is high, then
HCV RNA is performed because it is well correlated with
HCV transmission
ANTIBODY TO HEPATITIS A
 Infection with HAV results in ACUTE HEPATITIS only
 Anti-HAV is present and detectable in serum at the onset
of infection and persists for life
 IgM anti-HAV- persists in the serum for 3-12 months;
diagnostic marker of acute HAV infection
4 CASTILLO, J.LP.
ANTI-SMOOTH MUSCLE ANTIBODIES
 SMOOTH MUSCLE ANTIBODIES
 Directed against actin filaments in the cytoplasm of
hepatocytes
 Found commonly in the serum (60%) of patients with
chronic autoimmune hepatitis
 Detectable levels of SMAs are found:
o (<5%) in serum from healthy persons
o Primary biliary cirrhosis
o Acute viral hepatitis
o Infectious Mononucleosis (IM)
o chronic HCV infection
ANTI-MITOCHONDRIAL ANTIBODIES
 Found in <1% of healthy persons, in up to 94% of primary
biliary cirrhosis, and approximately 25% of chronic active
hepatitis.
 Useful in evaluating patients with jaundice (serum from
patients with jaundice due to extrahepatic biliary
obstruction will be negative for AMAs).
SERUM PROTEIN MARKERS FOR HEPATIC DISEASE
α-FETOPROTEIN
 Major serum protein in the fetus synthesized by fetal yolk
sac cells and embryonic hepatocytes
 Diagnostic usefulness of AFP:
o Identification of hepatocellular CA
o Serum AFP levels >400 ng/mL (95%)
 Serum AFP level:
o Modestly increase in Yolk Sack Tumor
o Mildly increase in alcoholic liver disease,
chronic hepatitis, and cirrhosis (100-200
ng/mL)
 Valuable for follow-up and detection of recurrent
disease
CERULOPLASMIN
 Glycoprotein synthesized in the liver, an acute-phase
reactant, a copper-containing oxidase enzyme and Cu+
donor
 Prinicipal role:
o Diagnosis of WILSON’S DISEASE
(hepatolenticular degeneration)
 Rare disease, characterized by:
 Decreased serum ceruloplasmin
 Levels
 Increased urine ceruloplasmin levels
 Accumulation of Cu in hepatocytes,
cornea (Kayser Fleischer rings), and
brain
 Accumulation of Cu within hepatic parenchyma eventually
leads to cirrhosis.
α1-ANTITRYPSIN (AAT)
 Glycoprotein synthesized in the liver, an acute-phase
reactant, and inhibitor of proteolysis by serine
proteases (chymotrypsin, elastase)
 AAT deficiency is associated with lung and liver disease:
o Pulmonary emphysema
o Cholestatic liver disease or cirrhosis
 L-08 LIVER FUNCTION TESTS
ACUTE-PHASE REACTANTS
 Refers to proteins that increases during episodes of
acute inflammation (eg, infection, surgery, myocardial
infarction)
o AAT
o Ceruloplasmin
o CRP (C-Reactive Protein)

KEY POINTS
1. If the possibilities of hemolysis and defective
Hemoglobin formation have been excluded, an
increased serum bilirubin level is typically an
indication of hepatobiliary dysfunction.

2. Although it is occasionally helpful to distinguish

between increased serum bilirubin concentration
resulting primarily from direct (conjugated) or indirect
(unconjugated) bilirubin, most cases of hepatobiliary
disease, inflammatory or cholestatic in adults result in
an increased direct bilirubin concentration.

3. Increased serum AST and ALT levels are

characteristics of hepatocellular damage.

4. An increased serum ALP level often indicates biliary

obstruction or infiltrative lesions of the liver.

5. Laboratory tests associated with the ability of the

liver to synthesize proteins (e.g., albumin and
prothrombin) are useful as prognostic markers of
liver disease.

6. Tests for viral Ags and/or Abs associated with the

hepatitis viruses (e.g., A, B, C) are used to distinguish
acute from chronic liver disease.

7. Quantification of viral nucleic acid levels in serum

may be helpful when evaluating chronic liver disease,
especially when the typical serologic tests for viral
Ags, Abs, or both are negative.

8. Anti-mitochondrial Abs is a marker for primary

biliary cirrhosis.

9. Smooth muscle Abs is a marker of chronic

autoimmune hepatitis.

Source:
Dr. Mila Amor Reyes, ppt lecture presentation

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 LABORATORY DIAGNOSIS
2A RENAL FUNCTION TESTS
L-09 Dr. Mila Am or Reyes | A.Y. 2018 -2019
Topic Outline
I. Renal Physiology
II. Glomerular Filtration Rate
Inulin
III. Creatinine
IV. BUN
V. Renal Concentrating Capacity
VI. Osmolality
VII. Specific Gravity
VIII. Water Deprivation Test
IX. Diabetes Insipidus
X. Renal Diluting Capacity
RENAL PHYSIOLOGY
 Normal kidney function depends on:
1. Renal blood flow must be appropriate
2. Glomerular filtration should be adequate
3. Renal tubular function should be normal
4. There must be no significant obstruction to urine
outflow
 Overall renal function and some aspects of its physiology
can be assessed by determination of RENAL
CLEARANCE.
 Elevations of either UREA or CREATININE may signal
RENAL FAILURE.
 In normal individuals, approximately 50% of renal function
may be lost before the tests exceeds the upper limits of
normal.
 CLEARANCE OF A SUBSTANCE- volume of plasma per
unit time that is cleared completely of that substance.
 MASS BALANCE PRINCIPLE- quantity of a substance
that enters the kidneys must equal the quantity that comes
out assuming the substance in question is neither
produced nor metabolized within the renal parenchyma.
 Vcl= CuVu/Ca
Vcl= Clearance of substance x
Vu= Volume of urine collected in a given time
Cu= Concentration of substance X in the urine
Ca= Concentration of substance X in the renal artery = Cs,
concentration of substance X in serum
GLOMERULAR FILTRATION RATE (GFR)
 Amount of ultrafiltrate initially formed in Bowman's space
per unit time (mL/min);
 Used as indicator of renal function dependent on:
o Permeability and surface area of the glomerular
capillary basement membrane
o Difference in hydrostatic pressure and
oncotic pressure between the glomerular
capillary lumen and Bowman's space
1 CASTILLO, J.LP.
 Using the mass balance principle, if substance X is
neither absorbed, metabolized, nor secreted along journey
from Bowman's space to the urinary bladder, then the
amount of substance X entering Bowman's space, is equal
to that eliminated in the urine.
 GFR= CuVu/Ca Vcl= GFR
 GFR is age dependent:
o Maximum is achieved during the 3rd decade of
life and decreases at the rate of 1 mL/min/year
from the 5th decade onward
 For substances that are secreted by renal tubular
epithelial cells into the tubular lumen, their urinary
concentration will be elevated, and the calculated
clearance of these substances will overestimate the true
GFR.
 For substances that are reabsorbed along the nephron,
their urinary concentration will be decreased, and the
calculated clearance will underestimate the true GFR.
INULIN
 Inert artificial substance that is freely filtered by the
glomeruli and is neither secreted nor reabsorbed by the
renal tubules.
 125I-labeled iothalamate- substance used to measure
GFR (usually available only in a research setting)
 No endogenously occurring substance that satisfies all the
requirements necessary to allow renal clearance to be
used to accurately estimate GFR, creatinine comes
close.
CREATININE
 Breakdown product of skeletal muscle-derived creatine
and phosphocreatine catabolism.
 NV:
o WOMEN: 0.6 to 1.0 mg/dL (53-88 µmol/L)
o MEN: 0.8 to 1.3 mg/dL (71-115 µmol/L)
 Note: Production is relatively constant within a given
individual throughout the day, but is a function of muscle
mass, and is both age-dependent and sex-dependent.
 Total body creatinine production: approximately 20
mg/kg/day
 Normally removed from the body almost exclusively by the
kidneys:
o 85% via glomerular filtration
o 15% secreted via renal tubules
 Virtually NO creatinine is absorbed along the nephron;
calculation of ClCr results in slight overestimation of GFR.
 In patients with renal failure, the fraction of creatinine
removed by renal tubular secretion is increased, and
error in the estimation of GFR obtained by calculation of
ClCr is even more pronounced.
 L-09 RENAL FUNCTION TESTS
METHODS OF CREATININE DETERMINATION
1. JAFFE REACTION- alkaline picrate chromogenic assay
 Colorimetric determination of creatinine-picric acid
complex
 Interfering chromogens: results in falsely high
values
o Protein
o Urea
o Glucose
o Ascorbic Acid (Vitamin C)
o Guanidine
o Acetone
o Cephalosporins
o a-ketoacids
(PU GAGA CA )
2. ENZYMATIC METHOD- enzymatic degradation
creatinine with creatinase
 Measuring Creatinine Clearance (ClCr) is time-
consuming and labor-intensive.
 Serum Creatinine (SCr) concentration is often
used to estimate renal function and GFR.
 Inverse relationship between GFR and Serum Creatinine
(Scr):
o e.g., in a patient with an initial serum creatinine
concentration of 0.6 mg/dL (53 µmol/L) and an
initial GFR of 100 mL/min, a decrease in GFR to
25 mL/min would raise the SCr to 2.4 mg/dL
(212 µmol/L)
 Two (2) instances in which serum creatinine concentration
may be FALSELY ELEVATED without indicating a
significant decrease in GFR:
o MASSIVE RHABDOMYOLYSIS- associated with
rapid release of large quantities of skeletal
muscle-derived creatinine into the blood.
o Drugs (e.g., cimetidine)- interfere with
tubular secretion of creatinine
 Measurement of Creatinine Clearance (ClCr) as an
estimate of GFR requires measurement of:
o Serum creatinine (SCr) concentration
o Urine creatinine (UCr) concentration
o 24-hour urine volume
 Sample Calculation:
 A 70-kg man collects 1.7L of urine over 24 hours. SCr is
1.1 mg/dL ((97 µmol/L) and UCr is 82 mg/dL (7248
µmol/L)
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BLOOD UREA NITROGEN (BUN)
 End product of protein catabolism
 Produced in the liver via the urea cycle, which converts
ammonia, derived from the breakdown of proteins, to
urea.
 Affected by:
o Excessive protein catabolism (e.g., febrile
illness)
o Inhibition of anabolism (e.g., treatment with
corticosteroids)
 Synthesis is also dependent on intact liver function
 NV:
o 10 to 15 mg/dL (3.6-5.4 mmol/L)
o Low values: (<10 mg/dL or 3.6 mmol/L) are
associated with overhydration
o High values: (50-150 mg/dL or 17.9-53.6
of mmol/L) signify impaired renal function
o Markedly elevated BUN concentration: (150-
250 mg/dL or 53.6- 89.3 mmol/L) is virtually
conclusive evidence of severe renal
dysfunction
 Urea is filtered by the glomeruli but is also significantly
reabsorbed by the renal tubular epithelium; amount
reabsorbed is inversely proportional to the urinary
flow rate.
 Amount reabsorbed is inversely proportional to the urinary
flow rate.
 BUN is NOT as useful a measure of renal function as is
Serum Creatinine (SCr) but may correlate better with
uremic symptoms than SCr concentration.
 In patients with very low GFRs consistent with severe
renal disease:
o Creatinine clearance (ClCr) significantly
overestimates the true GFR
o BUN clearance (ClBUN) consistently
underestimates GFR
o Note: If the clearances are averaged, a relatively
accurate estimate of the true GFR can be
obtained.
METHODS OF BLOOD UREA NITROGEN DETERMINATION
1. INDIRECT METHOD- which generates NH4+ from urea
through the use of bacterial enzyme urease.
 NH4+ is detected in a coupled reaction in which
glutamate dehydrogenase converts α-ketoglutarate to
glutamate with simultaneous oxidation of NADH to NAD
o Falsely low result: Citrate or Fluoride can inhibit
urease
o Falsely high result: Endogenous NH3
2. COLORIMETRIC METHOD- condensation of urea with
diacetyl group to form a chromogen, whose concentration is
measured spectrophotometrically.
 BUN: Serum Creatinine Ratio = 10:1 to 20:1
 Renal Parenchymal diseases- BUN and serum
creatinine (SCr) both rise, and BUN: SCr maintain a
similar ratio
 Increased BUN: SCr- compromised blood flow resulting
in enhance urea reabsorption:
o Dehydration
o Congestive Heart Failure
o Hepatorenal Syndrome
 L-09 RENAL FUNCTION TESTS
o Obstruction of the urinary tract
o Excess urea production from GIT bleeding,
fever, or catabolic drugs
 Decreased BUN: SCr – seen in:
o Low-protein diets
o Chronic hemodialysis (because urea is more
efficiently dialyzed than creatinine)
o Pregnancy (due to increased GFR, which has a
greater effect on urea excretion relative to
creatinine excretion)
RENAL CONCENTRATING CAPACITY
 The ability of the kidney to concentrate or dilute the
urine is important and complements the thirst
mechanism in maintaining the appropriate osmolality of
the plasma and extracellular fluid.
 NV: 280-290 mOsm/kg water
OSMOLALITY
 Measure of the number of solute molecules in solution,
independent of the size of the individual molecules.
 Measured by comparing the freezing point of a solution
with that of distilled water.
 The more concentrated a solution is, the higher its
osmolality, and the lower its freezing point.
SPECIFIC GRAVITY
 Ratio of the mass per unit volume of a solution, to the
mass per unit volume of distilled water (SG= 1.000)
 Affected by the size and number of particles in solution,
measured by a hydrometer or a REFRACTOMETER.
 Plasma and urine with an osmolality of 300 mOsm/kg
water has a SG of 1.010.
 Very dilute urine has a SG of 1.000 to 1.001.
 Moderately concentrated urine has a SG of 1.020.
 Urine with SG >1.022, in the absence of glucose, protein,
or radiocontrast material, suggests intact renal
concentrating capacity.
 Healthy kidneys can vary the osmolality (or tonicity) of
the urine from 50 mOsm/kg water (i.e., dilute or
hypotonic with respect to plasma) to 1200 mOsm/kg
water (concentrated or hypertonic) depending on the
solute load and free water balance.
WATER DEPRIVATION TEST
 Water deprivation results in:
o Concentrated urine (elevation of serum
osmolality), with release of ADH or vasopressin
which acts on the renal collecting ducts to
facilitate reabsorption of free water, and
o Stimulation of the thirst response
 Test of renal concentrating ability.
 Performed on patients who produce persistently dilute
urine.
o Measurement of body weight, serum and urine
osmolality, and serum ADH concentration at the
beginning and at the end of the test
o Careful monitoring of the patient to avoid marked
dehydration
o If the polyuric patient shows minimal evidence of
concentrating ability, a small dose of ADH is
administered, and serum and urine osmolalities
are measured
3 CASTILLO, J.LP.
DIABETES INSIPIDUS
 In NEUROGENIC DI- ADH deficiency; patients will
respond to the exogenously administered ADH with
concentrated urine and return of the elevated serum
osmolality to normal.
 In NEPHROGENIC DI — collecting duct epithelium
unresponsive to ADH with normal ADH level; patients will
continue to produce large quantities of dilute urine with
rising serum osmolality.
 Defective renal tonicity may cause an abnormal
deprivation test:
o Can be cause by drugs (e.g., furosemide),
ischemia, sickle cell disease, or compulsive
water drinking
RENAL DILUTING CAPACITY
 Tests of renal dilution, or the ability to excrete free water
 NOT commonly performed because of the potentially
serious adverse sequelae associated with water
intoxication.
KEY POINTS
1. Creatinine clearance measurements are useful in
estimating GFR and in assessing renal function.
2. Both colorimetric and enzymatic methods are available
for quantifying urine and serum creatinine concentrations used
in the calculation of creatinine clearance.
3. Urine creatinine measurements are useful in assessing
the adequacy of 24-hour urine collections. A healthy 70-kg
man normally excretes approximately 20 mg per kg day in the
urine.
4. Measurement of both creatinine and BUN clearances are
useful in obtaining an estimate of GFR in patients with severe
renal disease.
5. Urine SG measurements are used to estimate urine
osmolality;
6. Urine SG values greater than 1.022 suggest intact renal
concentrating ability in the absence of interfering substances
such as glucose, protein, or radiocontrast material.
7. The water deprivation test, supplemented by
administration of ADH, is useful in discriminating between
neurogenic DI and nephrogenic DI.
8. Tests of renal diluting capacity are NOT commonly
performed because of potential adverse sequelae associated
with water intoxication.
Source:
Dr. Mila Amor Reyes, ppt lecture presentation
 LABORATORY DIAGNOSIS
2A ENDOCRINE FUNCTION TESTS
L-07 Dr. Mila Am or Reyes | A.Y. 2018 -2019
PITUITARY FUNCTION
 Synthesis and secretion by the anterior pituitary is
controlled by the hypothalamus via hypophysiotropic
homones, and by the hormones of target glands
"negative feedback“
 Hormones secreted by the anterior pituitary:
o Growth Hormone
o Luteinizing Hormone
o Follicle-stimulating Hormone
o Thyroid-stimulating Hormone
o Adrenocorticotropic Hormone
o Prolactin
 Immunocytochemical and electron microscopic techniques
allow the cells of the anterior pituitary to be classified
according to their secretory products:
o ACIDOPHILS:
 Somatotropes secrete Growth
Hormone
 Lactotropes secrete Prolactin
o BASOPHILS:
 Thyrotropes secrete TSH
 Corticotropes secrete ACTH
 Gonadotropes secrete gonadotropins
ADRENOCORTICOTROPIC HORMONE (ACTH)
 Mainly stimulates the synthesis and secretion of
glucocorticoids, with minor effect on mineralocorticoids
and adrenal androgens.
 Secretion is stimulated by:
o Many types of stress
o Hypoglycemia
 Inhibited by cortisol
 Secreted in a pulsatile manner with diurnal rhythm
(highest in early morning hours)
THYROID-STIMULATING HORMONE (TSH)
 Stimulates the growth and function of the thyroid
gland (to produce T3 and T4).
 Secretion is regulated by the:
o Levels of thyroid hormones
o Thyrotropin-releasing hormone (TRH)
PROLACTIN
 Primary effect is the initiation and maintenance of lactation
in the postpartum period.
 Secretion is increased by stress, under tonic inhibition by
dopamine.
 Secreted in an episodic and pulsatile manner

LH & FSH
 Gonadotropins β-sub-unit confers the biologic specificity
of the hormone.
 In men:
o LH acts on Leydig cells to increase the
synthesis and secretion of testosterone;
o FSH acts on Sertoli cells and stimulates
spermatogenesis
o Sertoli cells produce inhibin, which inhibits FSH
secretion
 In women:
o LH stimulates estradiol and progesterone
production by the ovary;
o FSH is responsible for the development of the
ovarian follicle
GROWTH HORMONE (GH)
o LH surge in the mid-menstrual cycle is
 Stimulates linear growth mediated by somatomedins
responsible for ovulation, and maintains the
or IGFs, which stimulate protein synthesis.
corpus luteum and progesterone production.
 Stimulates lipolysis with antagonistic effect on insulin
 FSH and LH are under dual control of the
action.
hypothalamus and gonads;
 Secretion is stimulated by:
 Secreted in an episodic manner
o Exercise
 Gonadotropin-releasing hormone (GnRH):
o β-blockers
o Maintains basal gonadotropin secretion
o Amino acids
o Generates the phasic release of gonadotropins
o Dopamine
for ovulation
o Glucagon
o GHRH o Determines the onset of puberty
o Sleep
HYPOPITUITARISM
o Stress (hypoglycemia)
(E BAD GG SS )  Deficiency of one or more pituitary hormones
(panhypopituitarism)
o Clinical manifestations are not evident until at
 Secreted in an episodic and pulsatile manner
least 75% of the gland is destroyed

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 L-07 ENDOCRINE FUNCTION TESTS
 Causes of Hypopituitarism:  Cortisol and GH reserve- assessed by insulin-induced
o Tumors hypoglycemia
o Trauma Vascular disease (Sheehan's syndrome) o Following the inducement of adequate
o Irradiation hypoglycemia (40 mg/dL), cortisol levels should
o Granulomas be >20 ug/dL and GH levels should be 10 ng/mL
(TT IG ) o In children with suspected GH deficiency:
 Screening test with either L-dopa,
 GH DEFICIENCY- no obvious clinical manifestations glucagon, or exercise
but may contribute to: must be undertaken initially;
o tendency to fasting hypoglycemia in adults;  If GH response is inadequate (<5
o longitudinal growth is severely retarded in ng/mL)—proceed to insulin-induced
children hypoglycemia test
 TSH DEFICIENCY- “secondary hypothyroidism”
producing clinical picture similar to primary hypothyroidism PITUITARY TUMORS
with weakness, bradycardia, and delayed reflexes.  Most common cause of hypopituitarism, constitute 10%
of all intracranial tumors, classified into:
 ACTH DEFICIENCY- major clinical feature is tendency to o Secretory
spontaneous hypoglycemia without hyperpigmentation o Non-secretory
present with primary hypoadrenalism.  Craniopharyngioma- Most common pituitary tumor in
children
 PROLACTIN DEFICIENCY- major consequence is failure  Pituitary adenoma- Most common pituitary tumor in
of lactation, usually seen in Sheehan's syndrome. adults (<10mm diameter—microadenoma)
 Manifestations:
 GONADOTROPIN DEFICIENCY (LH & FSH): o Space-occupying lesions
o Results in delayed or partial puberty in children o Hypopituitarism
o More common in males o Hypersecretion of hormones
o KALLMANN'S SYNDROME- associated with
midline defects, nerve deafness, color-blindness,
and anosmia. CRANIOPHARYNGIOMA
o After puberty, clinical features in males include:  Develop from Rathke’s pouch
 Impotence  Suprasellar, non-secretory, and most are cystic
 Loss of libido  Most common pituitary tumors in children and young
 Loss of secondary sex adults
characteristics (facial, pubic, and  Clinical Presentation/s:
axillary o Raised ICP
hair loss) o Visual field defects
 Infertility (oligo- or azospermia) o Hypopituitarism
o Women may present with:  “Suprasellar calcification” (>70%) — hallmark of this
 Dyspareunia tumor
 Loss of libido
 Loss of secondary sex ACROMEGALY
characteristics  Increased secretion of GH before epiphyseal closure
 Oligomenorrhea results in gigantism, while in adults it results in
 Infertility acromegaly
o Both are usually due to a GH-producing
LABORATORY INVESTIGATION OF pituitary adenoma
HYPOPITUITARISM  Other causes:
 Routine investigation of patients suspected of having a o Ectopic GH or GHRH secretion in patients with
tumor- assessment of visual fields and imaging studies of carcinoids
the pituitary fossa (CT scan and MRI). o Lung Cancer
 Initial screening to assess pituitary function- measurement o Islet cell tumors
of TSH, free T4, LH, FSH, Prl, testosterone, and o Eutopic GHRH secretion from a hypothalamic
cortisol. hamartoma
o Pooled sample (3 samples, 20 mins. apart)  Acral enlargement (skin, subcutaneous tissue, and
should be obtained for LH, FSH, Prl, and skeletal overgrowth)
testosterone. o Increasing ring, gloves, or shoe size;
 Best assessment for gonadotropin deficiency in o Hyperhidrosis
premenopausal women- menstrual history. o Hypertension
 Measurement of IGF-1—GH deficiency (provided the o Diabetes
patient is not malnourished, chronically ill, or elderly, since o Cardiomyopathy (CMP)
these decreases IGF-1) o Osteoarthritis
 Useful index of ovulation is measurement of serum  Diagnosis is usually clinically obvious and can be
progesterone (> 5 ng/mL) confirmed by assessment of GH secretion

2 CASTILLO, J.LP.
 L-07 ENDOCRINE FUNCTION TESTS
o Fasting plasma GH levels: >5 ng/Ml DIABETES INSIPIDUS
o Single measurements are NOT reliable- pulsatile  Can result from:
nature and effect of stress on GH levels o Failure of ADH secretion (neurogenic, cranial or
o Simplest and most specific test: GH response to central)
the administration of 100g oral glucose o Failure of the kidneys to respond to ADH
 Normal Value- GH levels are (nephrogenic)
suppressed to <2 ng/mL at 60 mins.  Neurogenic, cranial or central DI- will develop if 80% of
 Acromegaly- do not suppressed the pathways are destroyed; rare disorder
adequately o Causes: trauma, idiopathic, tumors, infections,
 Measurement of IGF-1 level (somatomedin C) — vascular lesions, and granulomas
elevated in  Most common form of DI- idiopathic type (30%)
virtually all patients o Essential feature is “polyuria” (3-15 L) with dilute
 Criteria that constitute an adequate response to therapy: urine
o 1. basal GH level <5 ng/Ml o Can lead to hypertonic dehydration, which in
o 2. adequate suppression following intake of turn stimulates the thirst mechanism, resulting in
oral glucose polydipsia
o 3. normal level of IGF-1  WATER DEPRIVATION TEST- most common provocative
test
PROLACTINOMAS o Patients are dehydrated until hourly urine
 Most common secretory tumors of the pituitary osmolalities are constant (<30 mOsm/kg
gland: difference between consecutive samples);
o 8x more common in women plasma osmolality is obtained and ADH
 Women can present with: administered
o Galactorrhea
o Amenorrhea o Normal persons and in psychogenic
o Loss of libido polydipsia- urine osmolality > plasma osmolality
o Anovulation (300 mOsm/kg) at the end of dehydration and
o Infertility does NOT increase by >5% following ADH
o Effects of tumor expansion
 Men may present with: o In partial DI- urine osmolality > plasma
o Galactorrhea osmolality at the end of dehydration and
o Impotence increases by at least 9% following ADH
o Loss of libido
o Gynecosmastia o In severe DI- urine osmolality < plasma
o Infertility osmolality at the end of dehydration and
o Effects of tumor expansion increases by >50% following ADH
 In microadenomas- rest of pituitary function is
normal, basal testing of pituitary hormones o Should be terminated if body weight falls by >3%
o In macroadenomas- assess for hypopituitarism
 Several random measurements of Prolactin level with  Another useful test — ADH response to a hypertonic
pooled samples- most reliable test saline infusion or maximum dehydration, if ADH assays
are available.

SYNDROME OF INAPPROPRIATE ADH

SECRETION (SIADH)
 Disorder in which there is increased ADH secretion
despite subnormal plasma osmolality; water retention,
hyponatremia, and serum hypo-osmolality; suppression of
aldosterone secretion.
 If hypoNa+ is <125 mmol/L- anorexia, nausea, vomiting,
and headaches
 If hypoNa+ is <110 mmol/L- cerebral edema, irritability,
confusion, disorientation, convulsions, hemiparesis, and
coma
 Biochemical features:
o HypoNa+
o Low serum osmolality, urea, and uric acid;
o Urine Na+ > 30 mmol/L;
o Urine osmolality > plasma osmolality

3 CASTILLO, J.LP.
 L-07 ENDOCRINE FUNCTION TESTS
THYROID FUNCTION
 Because thyroid dysfunction is common, clinical
assessment is frequently undertaken
 It is essential to the integrity of the organism to closely
regulate thyroid metabolism
o Remarkably narrow “setpoint” for fT4 and fT3
(metabolically active form)
 Because >99% of T 4 and T3 is protein bound
(essentially inert), measurement of total levels is
misleading because it primarily reflects levels of binding
proteins, not thyroid function
o Bound hormones are reservoir for future release
to the tissues
 TSH assay alone is superior as a clinical test for subtle
thyroid abnormalities — will result in a sensitive and rapid
inverse change in the TSH level.

 TESTING STRATEGIES:
 For symptomatic patients — TSH-based testing is
effective for both hypothyroidism and hyperthyroidism
 If either is clinically suspected — measurement of both
TSH and fT4 indicated
 For screening asymptomatic patients — only TSH is
needed; fT4 is indicated only if TSH is abnormal
 Other Secretory Tumors:
 Undetectable TSH level, with or without fT4 elevation:
o CUSHING’S DISEASE- 3rd most common
o Autoimmune hyperthyroidism
secretory disorder of the pituitary gland due to
o Toxic nodular goiter
excess ACTH secretion
o Exogenous thyroxine overdose (most common)
o Pituitary tumors secreting glycoprotein hormones
(TSH, LH, & FSH)—uncommon

KEY POINTS
1. Disorders of the pituitary gland include syndromes of
excess and syndromes of deficiency.

2. Hypopituitarism is defined as deficiency of either one or

many pituitary hormones. The most common cause of
hypopituitarism is a pituitary tumor.

3. A pooled serum sample is desired for evaluating levels of

LH, FSH, Prl, and testosterone because they are secreted
in a pulsatile fashion.

4. Tumors of the pituitary can be broadly classified into

secretory and nonsecretory. The most common
secretory tumor is a “prolactinoma”.

5. Disorders of ADH secretion include DI and SIADH.

6. DI can be diagnosed by measuring serum and urine

osmolality following water deprivation, while the SIADH
can be diagnosed by measuring serum and urine
osmolality and urinary Na excretion.

4 CASTILLO, J.LP.
 L-07 ENDOCRINE FUNCTION TESTS
KEY POINTS
1. Free thyroid hormone levels are maintained within a
narrow range.

2. Rise or fall of fT 4 or fT3 is disclosed by the deviation of

TSH sensed by the hypothalamic-pituitary system. There
is a logarithmic TSH response to an arithmetic change in
thyroid hormone level.

3. TSH alone is the appropriate screening test for thyroid

function with reflex testing for fT4 on patients with
abnormal TSH levels.

4. Detectable TSH levels exclude the conventional forms of

autonomous thyroid gland-based hyperthyroidism.

5. Elevated TSH levels are essential for the diagnosis of

primary hypothyroidism; normal levels exclude this
diagnosis.

CAVEATS FOR THYROID TESTING ADRENAL GLAND FUNCTION

 Severe non-thyroid illness (eg, sepsis, shock, and multi-  ADRENAL CORTEX:
organ failure) may disrupt the physiologic relationships o Zona glomerulosa- secretes
and hypothalamic-pituitary response to fluctuating thyroid mineralocorticoids (aldosterone)
hormone levels — “sick-euthyroid” patient  Major effect is on Na and water
 Drugs may affect thyroid results: excretion
o Dopamine infusions- induce pharmacologic  Regulated by RAAS
hypopituitarism o Zona fascilulata- secrete glucocorticoids
o Hydroxycorticosteroids- alter the TSH (cortisol)
response o Zona reticularis- secrete sex steroids (DHEA-
o Amiodarome- induce hypo-, hyper-, or euthyroid SO4)
changes  Glucocorticoid secretion is controlled by the
hypothalamopituitary-adrenal axis
CONDITIONS NOT RELIABLY CATEGORIZED o CRF – ACTH – cortisol
BY A TSH ONLY-BASED TESTING STRATEGY o Negative feedback effect
 Secondary hypothyroidism resulting from pituitary or o Major effect is on glucose and protein
hypothalamic abnormality metabolism
 Secondary hyperthyroidism resulting from pituitary o Stress can have a major impact on this system
adenoma o Inherent rhythm in ACTH and cortisol secretion
 Pituitary or generalized resistance to thyroid hormone  Greatest in early morning, 7:00 AM-9:00
 Ectopic TSH production by a neoplasm PM;
 Lowest in the few hours before sleep,
MONITORING THERAPY 11:00 PM-12:00AM
 Goal of therapy: restoration of physiologic relationship
of ft 4 and pituitary secretion of TSH  ADRENAL MEDULLA- secretes catecholamines
 Achievement of normal TSH level — principal endpoint (epinephrine and norepinephrine)
for thyroid replacement therapy
 Patients on T4 therapy with elevated TSH levels and ADRENAL INSUFFICIENCY
normal or low fT4:  Loss of >90% of both adrenal glands
o Insufficient dose or noncompliant  PRIMARY ADRENAL INSUFFICIENCY
o Malabsorption o Autoimmune adrenalitis (70%)
 Patients on T4 therapy with undetectable TSH levelsand o Tuberculosis (20%)
normal fT4: o Adrenal hemorrhage
o Represents subclinical iatrogenic hyperthyroidism o Metastasis to the adrenal gland
— with potential risk of atrial fibrillation and bone o AIDS
resorption o Drugs (ketoconazole)
(A TAMAD )

 Clinical features:
o Weight loss
o Skin pigmentation
o Hypotension

5 CASTILLO, J.LP.
 L-07 ENDOCRINE FUNCTION TESTS
 Biochemical features:  Useful CONFIRMATORY TESTS:
o Hypoglycemia o Examination of the diurnal variation of
o HypoNa+ cortisol levels
o HyperK+ o Urinary free cortisol test
o Metabolic acidosis o Overnight dexamethasone and low-dose
o Azotemia dexamethasone suppression test

 RAPID ACTH STIMULATION TEST- most useful  In Cushing’s syndrome- diurnal variation is absent and
confirmatory test plasma cortisol levels in the later part of the afternoon and
o 250 µg cosyntropin is injected IM or IV, and at night >10 µg/dL
cortisol levels are obtained at baseline, and 30 to
60 mins following injection  URINARY FREE CORTISOL- very sensitive test,
o NV: basal cortisol > 6 µg/dL, the increment over increased in 95%
basal > 7 µg/dL, and peak value > 20 µg/dL
o Subnormal response- consistent with  OVERNIGHT DEXAMETHASONE SUPPRESSION
adrenocortical insufficiency TEST- 1mg dexamethasone is given at 11:00 PM and
o Normal response- does not rule out an impaired cortisol level is obtained at 8:00 AM the next morning
ACTH reserve (partial adrenal insufficiency) due  NV: <5 µg/dL
to hypothalamopituitary disease  Cushing’s syndrome: >10 µg/dL

 LOW-DOSE DEXAMETHASONE SUPPRESSION TEST-

 SECONDARY ADRENAL INSUFFICIENCY- exogenous 0.5 mg dexamethasone is given at 6-hour intervals for 48
glucocorticoids or hypothalamopituitary disease hours, and a 24-hour urinary 17 OHCS are obtained at
 Metyrapone test and insulin-induced hypoglycemia — baseline and on the 2nd day:
required to rule out secondary hypoadrenalism  NV:
 Metyrapone test- giving a dose of metyrapone at  Urinary 17-OHCS <4 mg/day or <1
midnight and measuring levels of plasma cortisol and 11- mg/g of creatinine,
deoxycortisol the next morning  Urinary free cortisol <20 µg/day
o Metyrapone works by inhibiting 11β-hydroxylase  95% Cushing’s syndrome have abnormal results with
and stimulating ACTH and 11-deoxycortisol failure to suppress
secretion
o NV: cortisol level <5 µg/dL, 11-deoxycortisol >7  False positive results that can result in failure of
µg/dL following metyrapone suppression:
o Normal response denotes adequate function of o Obesity
the pituitary adrenal axis o Chronic illness
 Prolonged ACTH stimulation test- 250 µg IV infusion o High estrogen levels
over 8 hours for 3 days; in patients with secondary o Alcoholism
hypoadrenalism there is a progressive rise in plasma o Depression
cortisol. o Anticonvulsants
(O CHADA )
CUSHING’S SYNDROME  Normal urinary cortisol is seen among:
 ACTH-dependent: o Simple obesity
o Cushing’s disease o High estrogen states
o Ectopic production of ACTH o Drugs (anticonvulsants)
 ACTH-independent:
o Adrenal adenoma or cancer  Tests to delineate the cause the Cushing’s syndrome:
 Most common cause: o Plasma ACTH level
o Hypothalamopituitary disease (70%) o High-dose dexamethasone suppression test
o Ectopic ACTH secretion o Tumor localization studies
o Small cell cancer of the lung o Inferior petrosal sinus sampling following
o Thymomas CRH
o Pancreatic islet cell tumors administration
o Carcinoid tumors
 Clinical features:  Normal plasma ACTH level: 10-52 pg/mL and should be
o Centripetal obesity, interpreted with concurrent cortisol level
o Hirsutism
o Facial plethora  Measurement of both cortisol and ACTH levels
o Menstrual disorders simultaneously between midnight and 2:00 AM or in the
o Myopathy late afternoon after 4:00 PM may prove useful in
o Purple striae distinguishing ACTH-dependent and ACTH-independent
o Hypertension Cushing’s syndrome.
o Easy bruisability o If plasma cortisol >15 µg/dL and ACTH level > 15
o Acne pg/mL, cortisol secretion is ACTH-dependent

6 CASTILLO, J.LP.
 L-07 ENDOCRINE FUNCTION TESTS
o In primary adrenal tumors- ACTH levels are
decreased, <10 pg/mL
o Ectopic ACTH syndrome — ACTH levels are
elevated, >200pg/mL
o Cushing’s disease — ACTH levels are between
40 and 200 pg/mL
 HIGH-DOSE DEXAMETHANOSE SUPPRESSION TEST-
2mg dexamethasone is given at 6-hour intervals for 48
hours and a 24-hour urinary 17-OHCS levels are obtained
at baseline and on the 2nd day
o In Cushing’s disease- >64% suppression of 17-
OHCS levels and >90% suppression of urinary
free cortisol levels
o Ectopic ACTH syndrome and adrenal tumors-
little or no suppression of the urinary 17-OHCS
levels
 MEASUREMENT OF ADRENAL ANDROGEN DHEA-
SO4- useful in differentiating primary adrenal adenoma
from cancer resulting in Cushing’s syndrome.
 INFERIOR PETROSAL SINUS SAMPLING- useful in
differentiating Cushing’s disease from ectopic ACTH
syndrome.
o CRH is administered and ACTH levels are
obtained simultaneously in the inferior petrosal
sinus and in the peripheral vein.
PRIMARY HYPERALDOSTERONISM
 Can be due to:
o Adrenal adenoma (most common cause)
o Bilateral hyperplasia of the zona glomerulosa
o Adrenal cancer
 Clinically present with:
o Hypertension
o Hypokalemic alkalosis
o Myopathy
o Urinary K >30 mEq/day
 Useful test — plasma and urinary aldosterone levels:
o plasma aldosterone response following salt
loading (should not be undertaken in the
presence of severe hypertension, diastolic
pressure >115 mmHg, or cardiac failure)
 To distinguish an adrenal adenoma from nodular
hyperplasia:
o In adrenal adenoma, decreased aldosterone
levels with posture;
o In nodular hyperplasia, increased aldosterone
levels with posture
o Useful confirmatory tests:
 CT Scan
 Venography
 Sampling of adrenal veins
7 CASTILLO, J.LP.
 Other causes of hypertension with hypokalemic
alkalosis:
o Cushing’s syndrome
o Adrenogenital syndrome
o Renin-secreting tumor
o Renal vascular hypertension
ADROGENITAL SYNDROME
 Results from partial deficiencies of the enzymes in the
biosynthetic pathways of cortisol, aldosterone, and
adrenal androgens
 Most common is 21-hydroxylase deficiency (>95%)-
results in increased production of adrenal androgens and
precursors prior to the block
o In females: ambigous genitalia, hirsutism and
oligomenorrhea
o In males: isosexual precocity
 Biochemical features:
o HypoNa+
o HyperK+
o Low plasma cortisol levels
o High plasma ACTH and DHEA-SO4 levels
o High urinary ketosteroids
o
 Most sensitive test- MEASUREMENT OF PLASMA 17-
HYDROXYPROGESTERONE (elevated)
 Second most common disorder is 11β-hydroxylase
deficiency:
o In females: ambigous genitalia due to increased
sex steroids
o Present with HPN due to increased
deoxycorticosterone
o Biochemical features:
 Low plasma cortisol
 High plasma ACTH
 High urinary ketosteroids
o Useful test:
o Measurement of plasma 11-deoxycortisol and
11- deoxycorticosterone
o Measurement of 17-hydroxyprogesterone (all
with elevated levels)
PHEOCHROMOCYTOMA
 Most common disorder of the adrenal medulla
 10% tumor- 10% extra-adrenal, 10% bilateral, 10%
malignant, 10% familial (Multiple Endocrine Neoplasia
type II- one or more endocrine glands are overactive or
form a tumor)
 Presents with hypertension, sweating, palpitations,
headaches, pallor
Useful tests: measurement of urinary metanephrines
and VMA (vanillylmandelic acid)
o NV: <1.3 mg/day (urinary metanephrines)
 In pheochromocytoma:
o Urinary metanephrines 2-3x normal
o Plasma catecholamines > 2000 pg/mL
o Failure to suppress cathecolamine levels < 500
pg/mL following clonidine administration
 L-07 ENDOCRINE FUNCTION TESTS
KEY POINTS
1. Disorders of the adrenal gland include syndromes of
deficiency and syndromes of excess, both of which are
uncommon but potentially treatable.

2. Adrenocortical insufficiency can be diagnosed by the rapid

cosyntropin challenge test.

3. To confirm a diagnosis of Cushing’s syndrome, the most

useful tests include measurement of 24-hour urinary free
cortisol levels and the low-dose dexamethasone
suppression test.

4. The most useful tests to confirm a diagnosis of primary

hyperaldosteronism include measurement of plasma and
urinary aldosterone and measurement of plasma renin.

5. The most useful test for the diagnosis of the commonest

variety of the adrenogenital syndrome is measurement of
plasma 17- hydroxyprogesterone.

6. Pheochromocytoma is a common secondary cause of

hypertension. The most useful biochemical test in the
diagnosis of pheochromocytoma is measurement of the
urinary metanephrines.

Source:
Dr. Mila Amor Reyes, ppt lecture presentation

8 CASTILLO, J.LP.