1 / 123

INTERPRETATION OF LAB TESTS

INTERPRETATION OF LAB TESTS. Barb Bancroft, RN, MSN www.barbbancroft.com BBancr9271@aol.com. Rule number one …. Know your own lab’s normal values Various methods of testing and various “normal ranges”…. Serum protein electrophoresis. List the plasma proteins 1) albumin

tudor
Download Presentation

INTERPRETATION OF LAB TESTS

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. INTERPRETATION OF LAB TESTS Barb Bancroft, RN, MSN www.barbbancroft.com BBancr9271@aol.com

  2. Rule number one … • Know your own lab’s normal values • Various methods of testing and various “normal ranges”…

  3. Serum protein electrophoresis • List the plasma proteins 1) albumin 2) globulins 3) fibrinogen • Is there a difference between serum proteins and plasma proteins?

  4. Yes. • The removal of fibrinogen = serum. • So, the serum proteins are albumin and the “globulins”. • Fibrinogen—(1.5-4.0 g/dL or 150 to 400 mg/dL) • hyperfibrinogenemia (greater than 400 g/dL) increases the risk of clotting • What conditions increase the risk of clotting? Obesity, venous stasis, hip and pelvic surgery, immobility, age

  5. What else? • Endogenous estrogen? • Estrogen excess increases fibrinogen • Combined oral contraceptives? The “old days” vs. today’s COCs… • HT? (hormone therapy) • Dose dependent…age dependent… • Aging and fibrinogen—increases by 1% per year after age 30

  6. What else? • Smoking increases fibrinogen • So how about smoking and estrogen, eg, oral contraceptives or HT in the PMF? • Use the patch! Or an IUD…

  7. Biological Rhythms and clotting • Liver produces clotting factors overnight • Clotting factors are highest in the a.m. • DVT (venous clot or red clot) is formed; breaks off in early a.m. and travels to lungs—Pulmonary embolism at 7:30 a.m. • MI (arterial clot or white clot)—inflammation (inflammatory mediators are highest in the a.m.) triggers plaque rupture; platelets are stickiest in the early a.m. due to highest blood sugar; platelet plug forms, triggers clotting cascade; takes 2 hours to form; MI at 9 a.m. • ASA inhibits platelet aggregation • Coumadin/Heparin inhibit clotting factors

  8. Total Serum Proteins • Albumin • Globulins • (Albumin comprises 2/3 of the total serum proteins; globulins 1/3) • A direct albumin level can be used to determine nutritional status and/or the prognosis in liver disease

  9. Serum Protein Electrophoresis—based on molecular weight and overall charge (positive or negative) • + - Well in the gel Electrical current running through gel

  10. Serum electrophoresis albumin globulins β α1 α2 Γ

  11. Albumin • Functions—holds water in the vascular space • Binds drugs (protein-bound vs. “free” drug) • Hypoalbuminemia (less than 3.0 g/dL or 30 g/L)—what are the causes? • Liver disease—decreased synthesis due to liver disease or due to an OLD liver…(1% rule) • Or leaky kidneys…

  12. Patient with ascites? • SAAG—serum ascites/albumin gradient; • SAAG=albuminserum / albuminascites • ratio greater than 1.1 is 97% predictive of portal hypertension as the cause of ascites • SAAG less than 1.1 is nonportal hypertension—nephrotic syndrome, infection (TB, fungal, CMV), pancreatic ascites, ovarian cancer, peritoneal carcinomatosis

  13. Kidney disease • Nephritis—1-2+ protein in the urine • Nephrosis—3-4+ protein in the urine • Protein in the urine is usually albumin—macroalbuminuria with 1+-4+ • “Early” and reversible kidney disease in the diabetic or hypertensive patients is manifested by spilling “microalbuminuria” • TREAT with “PRILS”-ACE INHIBITORS

  14. “Prils”—The ACE inhibitors • Captopril (Capoten) • Enalapril (Vasotec) • Lisinopril (Prinivil, Zestril) • Perindopril (Aceon) • Moxepril (Univasc) • Benazepril (Lotensin) • Quinapril (Accupril) • Trandolapril (Mavik) • Ramipril (Altace) • Etc…

  15. “Angie” and the healthy kidney… • Afferent arteriole (vasodilated via (prostaglandins) • Blood entering glomerulus • Glomerulus→filter • Efferent arteriole (vasoconstricted via (angiotensin 2) • Blood exiting glomerulus PG filter AT2 Toilet

  16. “Angie, the “prils” and the Diabetic/hypertensive Kidney…hyperglycemia/HTN • Afferent arteriole (  vasodilation by (  prostaglandins) • Blood entering glomerulus • Glomerulus→filter • Efferent arteriole (  vasoconstriction via (  angiotensin 2) • Blood exiting glomerulus Microalbuminuria**

  17. The elderly • The 1% rule • The process of senescence begins at ___? • 1% decline in function per year in organ systems such as the liver • Serum albumin in the elderly • Decreased binding sites for drugs—increased bioavailability of drugs and drug toxicity

  18. The globulins… The alpha 1 globulins— • High-density lipoprotein—the good guy • HDL’s clear excess cholesterol from the blood; HDL’s are also potent “anti-oxidants” and prevent LDL from oxidizing; the HDLs are also potent “anti-inflammatory” lipoproteins; keep levels above 40 mg/dL (1.04 mmol/L) and above 60 mg/dL (≥ 1.55 mmol/L) would be ideal

  19. So if HDLs are good for you, how can we boost HDLs? • Eat right— garlic, beans, omega-3 fatty acids, fiber, almonds (and other nuts), plant stanols (Take Control, Benechol, Smart Balance) • Decrease saturated and trans fats

  20. What else boosts HDLs? • Exercise • Exercise • Ethanol

  21. Drink to boost HDLs… • 5 oz of wine of any color—This amount→ • Guys, you can have 2 glasses • How much of the hard stuff? 1 ounce for women 2 ounces for men • How much beer? 12 ounces for women 24 ounces for men

  22. So, what’s my motto? • Run a mile, drink a beer, eat a bowl of beans and pop a Premarin… • Have a 5-ounce glass of chardonnay with a delicious salmon dinner with my Mom… • OR…

  23. Increasing HDLs • Decrease carbohydrate intake • Say YES to drugs… • Niacin/Niaspan boosts HDL the most—up to 25% • Drugs— the “statin” sisters are prescribed primarily to lower LDL cholesterol but can boost HDL by about 6%; rosuvastatin boosts by 12%)– lovastatin (Mevacor), (simvastatin/Zocor, rosuvastatin/Crestor)**, atorvastatin (Lipitor), fluvastatin/Lescol, pravastatin/(Pravachol) • Metformin (Glucophage) increases HDLs

  24. Alpha-2 globulins • Transport proteins—transferrin (iron), Thyroid binding globulin (TBG), ceruloplasmin (copper)

  25. Beta globulins—the bad guys • LDLs (low density lipoproteins)—directly deposit into the walls of the arteries via the process of oxidation • The higher the LDLs, the greater the risk for atherosclerosis • Particle size plays a role as well • Small, dense LDLs vs. Large, loose LDLs

  26. LDL guidelines • Guidelines—with CAD or a risk equivalent (stroke, peripheral arterial disease), the LDL should be 70 mg/dL (2.0 mmol/L or even lower to 1.8 mmol/L) • For the rest of us with other risk factors—100 mg/dL (<2.85 mmol/L) • Unless you’re perfect…--130 mg/dL (<3.37 mmol/L)

  27. Risk factors for increased LDLs • Diet high in trans and saturated fats • Smoking • High iron levels • High insulin levels • Couch potato • Fat around the middle

  28. LDL reduction • If you’re boosting HDLs, you’re reducing LDLs…

  29. Say YES to statins—the “statin” sisters… • The statins inhibit the enzyme in the liver responsible for producing LDL-cholesterol • Since the liver works overtime at night, giving the statin drugs in the evening provides an even greater reduction in LDLs • Statins decrease plaque formation, stabilize plaques, prevent plaque rupture

  30. VLDL (very low density lipoproteins)--triglycerides • What increases TG? High fructose corn syrup, alcohol, pure sugar • Are triglycerides bad for you? Yes, in excess--Increased risk of heart disease, high risk of PN and fatty liver in the diabetic • Ideal is less than 150 mg/dL (1.70 mmol/L) • Borderline high is 150-199 (1.70-2.25 mmol/L)

  31. Marine-based omega-3 fatty acids lower TG • Prescription fish oil is Lovaza • How about non-prescription fish oil? • DHA and EPA should total 1000 mg/day for patients with high triglycerides so READ THE LABEL • May see a Cardiologist prescribe even higher doses of fish oil depending on level of triglycerides

  32. Total cholesterol—screening purposes only—best to do the LIPID PROFILE • Lipid profile after an 8 to 12 hour fast • Patient with triglycerides above 250 mg/dL (2.81 mmol/L) (and an HDL less than 40 mg/dL (1.04 mmol/L)—THINK… 1) Type 2 Diabetes (check the fasting blood sugar (4.1-5.9) or hemoglobin A1C (4-6)) 2) Hypothyroidism (TSH) (0.4-4.2 μU/mL or mU/L) for 21-54 yo; 0.5-8.9 μU/mL or mU/L for 55-87)

  33. WBC and DIFFERENTIAL • 5 types of mature WBC’s and one immature WBC circulate in the “cold, cruel world” known as peripheral blood • Normal range 5,000 to 10,000 (3500-12000) (5 to 10 with a range of 3.5-12)

  34. The List… • Neutrophil (segs (57-63%) of the total white count; acute inflammation, acute necrosis, acute bacterial infection(1.51-7.07) Bands (0-4%) (0.00-.51)—precursor to the neutrophil • Lymphocytes (30%)-first responder to viruses; cells of the immune system (0.65-2.8) • Monocytes (4%)—cells of chronic inflammation (0.00-0.51) • Eosinophils (3%)—cells that respond to parasites and allergies (0.00-0.42) • Basophils (less than 1%)—who cares? Contain histamine (0.00-0.16)

  35. The granulocytes… • All of the cells with the last name “phil” are called granulocytes • The neutrophils (segs) are most important—acute inflammation, acute necrosis—phagocytic • The eosinophils are increased in allergic responses and with parasitic infections (Carlotta) • Basophils—allergies and anaphylaxis

  36. 5 types of WBCs • Neutrophils (seg)—(phagocyte)-- only job in the world is to EAT until it dies • Cell of acute inflammation • First responder to bacterial invasion • Loves acute necrotic tissue • 57-63% of total WBC (1.51-7.07)

  37. How do neutrophils grow up? • Stem cells • Myeloblast (BM) • Promyeloctye (BM) • Myelocyte (BM) • Metamyelocyte (juvenile) (BM) • Band neutrophil (BM and PB) • Segmented neutrophil (BM and PB)

  38. Neutrophils • Neutrophils (segs) are produced in about 8-10 days; leave the bone marrow and live in the blood for 5-6 hours; migrate into tissues and eat for 36-72 hours; • released rapidly in response to virulent organisms such as strep, staph, E. coli, H. flu, meningococcus, Pseudomonas • Acute necrosis—MI, gangrene of the bowel, acute appendicitis

  39. Shift to the left • During the time of acute need, the bone marrow is functioning overtime…massive production results in a partial loss of quality control concerning the level of maturity of the cells that are released into the peripheral blood • WBC and diff will show an increased number of neutrophils and bands and maybe even a metamyelocyte (juvenile) or two— • shift toward immaturity • Shift-to-the-left—increased number of bands • What is the usual number of bands? 0-4%

  40. Clinical conditions with an increased WBC and “shift-to-the-left” • GABHS • Pyelonephritis • Acute appendicitis • Bacterial meningitis

  41. Drugs and neutropenia • Chemotherapy (all patients)—ONCOLOGIC EMERG. • Cimetidine (Tagamet), ranitidine (Zantac) • Carbamazepine (Tegretal); phenytoin • Captopril (Capoten), enalapril (Vasotec), amiodarone, quinidine • Zidovudine (Retrovir) • Clozapine (Clozaril) • Metronidozole (Flagyl) • Gentamicin, clindamycin, imipenem, PCNs, tetracyclines • Azothiaprine (Imuran) • PTU

  42. Neutrophils …normal function • Margination, pavementing, migration, engulfment and degranulation Yum.

  43. Prednisone and the neutrophil • Inhibits migration and degranulation, hence its anti-inflammatory properties • Prednisone also increases blood sugar; high blood sugars can inhibit the function of neutrophils • Diabetes– Blood glucose greater than 180 mg/dL (9.99 mmol/L) inhibits neutrophil migration (normal blood glucose is 74-106 mg/dL or 4.1-5.9 mmol/L) • Elderly with decreased migration of segs, increases infection susceptibility • Fever increases the migration of segs—is fever good for you? YES!

  44. STRESS! • Stress and the WBC • Screaming kids • 24-hours post-op • Last trimester of pregnancy • No bands

  45. Inflammation—C-reactive protein • C-reactive protein -- < 1 mg/dL or < 10 mg/L; • rapid, marked increases occur with inflammation, infection, trauma, tissue necrosis, malignancies, and autoimmune diseases; Increases quickly and dramatically in response to stimuli, and decreases substantially with resolution of the disorder • hs-CRP (vascular inflammation) and coronary artery disease risk level low risk < 1 mg/L; Average 1-3 mg/L; high risk > 3 mg/L (Noncardiovascular causes should be considered if values are > 10 mg/L) PROGNOSTIC INDICATOR (and screening for CV inflammation—next slide)

  46. hs-CRP—low levels of inflammation in the vascular system • High sensitivity assay indicates a high risk of vascular inflammation and subsequent cardiac risk • Use of hs-CRP + lipid values together are more accurate at predicting risk than lipid studies alone • IL-6 and TNF-α are produced within unstable plaques as well as from adipocytes in abdominal fat, which in turn increases hs-CRP production by the liver • The bigger the waistline the greater the hs-CRP • YIKES…so what should your waistline be? • Ridker PM et al. N Engl J of Med 2000; 342:836-43; Ridker PM et al. N Engl J of Med 1997;336:973-9)

  47. What can reduce hs-CRP? • Exercise • Loss of abdominal fat • Statins • Pioglitazone (Actos) • Aspirin • Omega-3 fatty acids • Nuts • The Mediterranean diet is anti-inflammatory

  48. Inflammation—the sed rate • Sed rate—rate of the settling of RBCs in anticoagulated blood; low sensitivity and specificity; many factors can influence the sed rate; used as a screening test and a prognostic indicator • Newborn—1-2mm/hr • Neonates and children—3-13 mm/hr • Post adolescent male (less than 40 years)—1-15 mm/hr • Post-adolescent female (less than 40 years)—1-20 mm/hr • Over forty years—the maximum normal ESR at a given age is: Males age in years/2; Females age in years + 10/2

  49. Monocyte/Macrophage • Monocyte in blood, macrophage in tissue (Kupffer cell in liver, microglial cell in brain, osteoclast in bone, mesangial cell in kidney) • Phagocytes that respond much slower than the seg (2-4 days vs. 5-10 minutes for the seg) • Eats for months • Cell of chronic inflammation

  50. Chronic inflammation--TB • Macrophages circling the “pathogen” is known as a granuloma • Granulomatous diseases are chronic inflammatory diseases with “osis” as a last name…tuberculosis, histoplasmosis, sarcoidosis, amyloidosis • Macrophages secrete numerous cytokines—one is known as TNF-alpha (tumor necrosis factor-alpha) to contain the tubercle bacillis…

More Related