1. Electrolytes
Part 2

2. Bicarbonate 2nd most abundant anion of ECF.
Major component of the HCO3- /H2CO3 buffering system.
Serves as a transport form for CO2 produced from metabolic processes in tissues
HCO3- accounting for more than 90% of the total CO2 at physiologic pH
Total CO2 measurement is indicative of HCO3- measurement
HCO3-

3. Bicarbonate
Carbonic anhydrase in RBCs converts CO2 and H2O to carbonic acid, which dissociates into H+ and HCO3-.
 HCO3- diffuses out of the cell in exchange for Cl- to maintain ionic charge neutrality within the cell (chloride shift)
This process converts potentially toxic CO2 in the plasma to an effective buffer: HCO3-
HCO3- buffers excess H+ by combining with acid, then eventually dissociating into H2O and CO2 in the lungs where the acidic gas CO2 is eliminated.

4. Regulation Bicarbonate conc. is regulated both in:
Kidneys through increased or decreased tubular reabsorption
And in lungs through exhalation of gaseous CO2 and H2O
Decreased levels of HCO3- in plasma result in acid-base disorder (acidosis)
Increased levels result in alkalosis

5. Alkalosis & Acidosis In alkalosis, In acidosis
a relative increase in HCO3- compared to CO2,
the kidneys increase excretion of HCO3- into the urine,
carrying along a cation such as Na+.
This loss of HCO3- from the body helps correct pH.
In acidosis
The body increases excretion of H+ into the urine.
In addition, HCO3- reabsorption is virtually complete, with 90% of the filtered HCO3- reabsorbed in the proximal tubule and the remainder in the distal tubule.

6. Assay Two common methods: Ion selective electrode Enzymatic:
converts all forms of CO2 to HCO3;
HCO3 is used to carboxylate phosphoenolpyruvate.
Coupled enzyme reaction that measures the amount of NADH consumed.
The rate of absorbance change is proportional to amount of CO2 present.

7. Assay

8. Magnesium
4th most abundant cation in the body and 2nd most abundant intracellular cation.
53 % of Mg found in the bone, 46 % in muscle and tissue, <1% is present in the serum & RBCs.
The Mg circulating in serum
one third-bound to albumin,
of the remaining two thirds-
61% is in the free or ionized form,
5 % bound to phosphate and citrate.
Free form is physiologically active.
Remaining is bound to other ions
Mg2+

9. Regulation of Magnesium
Regulated by dietary intake, intestine may absorb % of dietary intake and body needs.
Regulation of body Mg2+ is controlled largely by the kidney, which can:
reabsorb Mg2+ in deficiency states
or readily excrete excess Mg2+ in overload states
Form of magnesium and food present with magnesium alter absorption 
2%-5% is reabsorbed in the DCT
25%-30% is reabsorbed by PCT  
50%-60% of filtered Mg2+ is reabsorbed in Henle's loop

10. Regulation of Magnesium
Mg2+ regulation is related to that of Ca2+ and Na+.
Parathyroid hormone (PTH) increases the renal reabsorption of Mg2+ and enhances the absorption of Mg2+ in the intestine.
Aldosterone and thyroxine apparently have the opposite effect of PTH in the kidney, increasing the renal excretion of Mg2+

11. Clinical Significance
Roles in the body:
Myocardial rhythm and contraction
It is an essential cofactor of more than 300 enzymes,
Regulation of ATPase ion pump
Abnormal levels related to cardiovascular, metabolic, and neuromuscular disorders.

12. Hypo- & Hypermagnesaemia
Hypomagnesaemia:
Reduce intake
Decreased absorption (GI disorders, Malabsorption syndromes)
Increased excretion (as a result of various renal and endocrine disorders)
Hypermagnesaemia:
Decreased excretion (Adrenal insufficiency )
Increased intake

13. Assay Methods (colormetric) Calmagite Formazan dye Methylthymol blue
Mg2+ binds with calmagite to form a reddish- violet complex
Formazan dye
Mg2+ binds with the dye to form a colored complex
Methylthymol blue
Mg2+ binds with the chromogen to form a colored complex
Reference Range : mmol/L
Naphthol sulphonic acid. Calmagite is a complexometric indicator used in analytical chemistry to identify the presence of metal ions in solution

14. Digoxin is also used to treat atrial fibrillation, a heart rhythm disorder of the atria (the upper chambers of the heart that allow blood to flow into the heart).
3.5 – 5.0
0.6 – 1.2
2.15 – 2.55

15. Hypokalemia, hypocalcemia, and hypomagnesemia are all possible causes for cardiac arrhythmia.
Prolonged diuretic use can lead to magnesium loss.

16. Hypomagnesemia can cause decreased levels of potassium and calcium.
The exact mechanism for hypokalemia is not completely understood; however, it is known that magnesium is required for normal Na+ -K+ pump activity, which is responsible for active transport of K +
Magnesium deficiency can impair PTH release and target tissue response, leading to hypocalcemia.
Increase excretion of K through distal tubules

17. Providing magnesium therapy alone may correct the hypokalemia and hypocalcemia.
Replenishment of either potassium or calcium alone often does not remedy the disorder unless magnesium therapy is provided.

18. Calcium 99 % of calcium is associated with bone tissue
Only 1 % of body calcium is in the plasma
45 % ionized (active form)
40 % protein bound
15 % bound to other compounds
Critical component of cardiac function
Decreased ionized Ca2+ concentrations in blood can cause neuromuscular irritability
Tetany is a medical sign, the involuntary contraction of muscles

19. Regulation
Three hormones, PTH, vitamin D, and calcitonin, are known to regulate serum Ca2+ by altering their secretion rate in response to changes in ionized Ca2+.
Decreased plasma ionized Ca stimulates release of PTH
PTH activates a process known as bone resorption
PTH increases renal reabsorption of Calcium
PTH stimulates Vitamin D activation
Vitamin D increases GI absorption of Calcium
Bone resorption is resorption of bone tissue, that is, the process by which osteoclasts break down the tissue in bones
Calcitonin exerts its Ca2+-lowering effect by inhibiting the actions of both PTH and vitamin D

20. Regulation
osteoclasts

21. Clinical Applications
Both total Ca2+ and ionized Ca2+ measurements are available in many laboratories,
Ionized Ca2+ is usually a more sensitive and specific marker for Ca2+ disorders.
Causes of hypocalcemia
Hypoparathyroidism
Vitamin D deficiency
Renal disease
Hypoalbuminemia (total calcium only, ionized not affected)
2.15 – 2.55 mmol/l

22. Clinical Applications
Causes of hypercalcemia
Hyperparathyroidism
Malignancy (many tumors produce PTH-related peptide (PTH-rP), which binds to normal PTH receptors
hyperthyroidism can sometimes cause hyperparathyroidism because of the proximity

23. Assay Methods
The two commonly used methods for total Ca2+ analysis which form a complex with Ca2+ use either:
ortho-cresolphthalein complexone (CPC)
or arsenzo III dye
Adult reference range (total): mg/dL
 Ionized calcium: mg/dL
Current commercial analyzers that measure ionized/free Ca2+ use ISEs for this measurement.

24. Phosphate Element found everywhere in living cells
Participates in various biochemical processes
Most significant: ATP, Creatine Phosphate, phosphoenolpyruvate reactions.
Important compound in the release of O2 from Hb (2,3-diphosphoglycerate)
(DNA) and ribonucleic acid (RNA) are complex phosphodiesters

25. Phosphate
HPO42-
The concentration of all phosphate compounds in blood is about 12 mg/dL
most of that is organic phosphate
and only about 3 to 4 mg/dL is inorganic phosphate.
Phosphate is the predominant intracellular anion, with intracellular concentrations varying, depending on the type of cell
less than 1% is active in the serum/plasma

26. Regulation Phosphate in blood may be:
absorbed in the intestine from dietary sources,
released from cells into blood,
and lost from bone.
In healthy individuals, all these processes are relatively constant and easily regulated by:
renal excretion
or reabsorption of phosphate.

27. Regulation Renal regulation is affected by factors such as: Vitamin D,
increases both phosphate absorption in the intestine and phosphate reabsorption in the kidney
PTH,
lowers blood concentrations by increasing renal excretion.

28. Clinical Application Hypophosphatemia: Hyperphosphatemia:
Intracellular shift
Hyperparathyroidism
Renal tubular defect
Hyperphosphatemia:
Increase intake
Decrease excretion
Cell lysis
Acute respiratory alkalosis also causes intracellular shift of potassium and phosphates potentially resulting in hypokalemia and hypophosphatemia
the glycolytic pathway is stimulated which causes intracellular shift of phosphate

29. Assay Methods
Most of the current methods involve the formation of an ammonium phosphomolybdate complex.
This colorless complex can be measured by ultraviolet absorption at 340 nm
or can be reduced to form molybdenum blue, a stable blue chromophore, which is read between 600 and 700 nm.
Adult reference range: mg/dL

30. [Na]+ [K] + [other cations] = [Cl] + [HCO3] + [other anions]
Anion Gap
Body water compartments exist in a state of electroneutrality (anions=cations)
Routine measurements: Na, K, Cl & HCO3 levels
Anion Gap is the difference between unmeasured anions and unmeasured cations.
Formula: AG=(Na + K)- (Cl + HCO3)
The "real" balance is given by the equation:
    [Na]+ [K] + [other cations] = [Cl] + [HCO3] + [other anions]
([Na]+ [K]) - ([Cl] + [HCO3])= [other anions] - [other cations] = "Anion Gap“
8-16 or mmol/l

32. Anion Gap
Some of the unmeasured cations (~7mmol/L) include calcium, magnesium, and most other minerals.
Unmeasured anions (~24 mmol/L) include proteins like albumin, and phosphates, sulfates, etc.
There are always more unmeasured anions than cations, and thus the "anion gap" equation is always greater than zero.
It has a reference range of mmol/L

33. Clinical Uses of the Anion Gap
An elevated anion gap may be caused by:
uremia/renal failure, which leads to PO4- and SO42- retention;
ketoacidosis, as seen in cases of starvation or diabetes;
methanol, ethanol poisoning
and instrument error.
Low anion gap values are rare but may be seen with:
hypoalbuminemia (decrease in unmeasured anions)
or severe hypercalcemia (increase in unmeasured cations).
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