CLINIC AL INVESTIGATIONS

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ECG - Learning objectives

Essential

Pre reading
9 Correctly identify major anatomical features of the heart :4 chambers, valves, major vessels (
aorta, vena cavae, pulmonary vessels) conducting system, main coronary arteries.
9 Understand the orientation of the heart in the thorax

In course
9 Correctly identify which ECG leads correspond to which anatomical part of heart
9 Know how each feature of ECG corresponds to underlying cardiac electrical activity
9 Correctly identify the following features on an ECG:
o Calibrati on
o Rate (n.b. be able to ‘eyeball’ rate as well as accurately calculate)
o Rhythm : sinus/not sin us
o Axis
o Major arrhythmias: sinus tachycard ia, sinus bradycardia, AF, VF, ectopic beats
o LBBB, RBBB, first degree heart blo ck
o Chamber hypertrop hy
o Ischaemic changes: ST segment and T wave changes (stable angina pectoris and varying degrees
of ACS including unstable angina, STEMI and non-STEMI)
o Effect of abnormalities in electrol yte levels particularly potassium and calciu m

Desirable

Correctly identify the following features in an ECG:

o Pericarditis
o 2nd + 3rd degree block
o VT + SVT
o Pulmonary embolism
o Low voltage (hypothyroidism, pericardial effusion, obesity, COPD)
o QT changes including congenital prolonged QT
o Wolf-Parkinson-White syndrome
o Pacemaker spikes and complexes
o Atrial flutter

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 ECG Tutorials

1. History of the ECG. 4. Orientation of leads

2. Information obtained from an ECG 5. ECG paper
3. Anatomy of the heart 6. ECG interpretation: (15 points)

1. History

The ECG has been in use for over a century. A British physiologist, Augustus Waller, performed the
first ECG recording in 1887, and he gave demonstrations of his technique, using his dog, Jimmy, as the
“patient”. Einthoven, from Holland, was present at such a demonstration. Willem Einthoven constructed
his well-known triangle and the hexaxial system to help us gain further insight into the electrical activity
of the heart.
2. Information obtainable from an ECG

ECGs can give us much information about the heart and also give us clues about other aspects of an
individual’s state of health, such as:
Rhythm – sinus/non-sinus
Conduction – normal/abnormal
Size of heart chambers
Presence of ischaemic heart disease
Pulmonary embolism
Inflammation of the pericardium/effusion
Emphysema
Drugs the patient may be on e.g. Digoxin, Calcium channel blockers
Electrolyte status of the patient – potassium, calcium levels
Temperature – pyrexia or hypothermia
Endocrine status – AF in thyrotoxicosis; bradycardia in hypothyroidism
Raised intracranial pressure
In ischaemic heart disease, the ECG may give us several pieces of information, such as:

• The location of the affected area of myocardium (in order of frequency)

Antero-septal area
Inferior surface of the heart
Antero-lateral aspect of the left ventricle etc
•Whether the full thickness of the ventricular wall or only part of it is involved

This is made evident by the presence or absence of pathological Q waves, and the situation of the ST
segment. (ST elevation in transmural infarction; ST depression in sub-endocardial MI)
• Whether there are any obvious sequelae of the infarction, such as:

Cardiac failure (sinus tachycardia)

Rhythm abnormalities
Left ventricular aneurysm (persistently elevated ST segment)

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3. Anatomy of the heart

Heart and Great Vessels

Sternocostal Aspect

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 Cuta wayof the heart

Oblique section through right and left ventricles

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4. Orientation of leads

ƕ Horizontal plane leads

Anterior Chest Leads

Location of theelectrodes forthe chest (precordial) leads

The positive poles of the anterior

chest leads point anteriorly, and the negative poles point posteriorly.

The positivepole softhe precordial chest leads p oint anteri orly and the negatives poles point posteriorly.

Posterior Chest Leads Right-sided Chest Leads

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ƕ Frontal plane leads

The Limb Leads - Standard and Augmented Leads

Standard Leads Augmented Leads

Standard lead I
Standard lead II RA ņve LA +ve RA AVL LA +ve; RA, LL ņve LL
Standard lead III ņve LL +ve LA AVF +ve; RA, LA ņve RA
ņve LL +ve AVR +ve; LA, LL ņve

aVL aVF aVR

The six frontal plane (A) and six horizontal plane (B) leads provide a three-dimensional representation of
cardiac electrical activity.

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 Areas of the myocardium viewed by specific leads

Std II, Std III, aVF Inferior (diaphragmatic) surface of LV Right

ventricle Right and left atria Interventricular
Lead V1
septum (superior aspect) Endocardial aspect of
the posterior left ventricle (Thus V1 has a view of
all four cardiac chambers) Interventricular
septum (superior aspect) Endocardial aspect of
Lead V2 posterior left ventricle. Interventricular septum
(inferior aspect) Interventricular septum (inferior
aspect) Apex Lateral aspect of left ventricle
(inferior aspect) Lateral aspect of left ventricle
(superior aspect) Endocardial aspect of left
Lead V3 ventricle

Lead V4

Leads V5, V6

Std I, aVL

aVR

5. ECG paper
The ECG is recorded such that
Ɠ the 6 limb leads (standard & augmented) are recorded on the left
(pink) Ɠ the 6 chest (V) leads on the right (yellow)
Ɠ the rhythm strip at the bottom (blue), either Std Lead II or Lead V1.
c

The ECG paper consists of small squares 1mm x 1mm, and big squares 5mm x 5mm

In the horizontal plane

The value of a big square (5mm) is 0.2 seconds; a small square (1mm) is 0.04seconds.
In the vertical plane
The value of two big squares (10mm) is 1millivolt (mV), so each small square in the vertical plane is
equivalent to 0.1mV

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6. ECG interpretation: PQRSTU

When interpreting an ECG recording, we need to assess the following:

1. Calibration 2. QRS: 8. Pathological Q waves 12. ST segment

Rate 9. Duration 13. T wave
3. Rhythm 10. Voltage 14. QT interval
4. Axis 11. Configuration 15. U wave
5. P wave
6. PR interval 7.
PR segment

To group these observations another way, we need to assess:

1. Calibration
2. Rate, rhythm and
– P, T and U waves (and any other waves, such as delta or J waves)
axis 3. The waves
4. The QRS complexes
PR and
5. The segments – ST
PR and
6. The intervals – QT

1. Calibration The ECG is calibrated such that the 1mV standardisation mark is 10 mm tall and
the horizontal line of the mark is 5mm wide (0.2 seconds) This means that the
ECG is being recorded at 25mm/second

Normal 10mm/mV & 25mm/second calibration. Note the box-shaped calibration mark to
the left of the complexes, two big squares tall & one big square wide

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2. Rate
Normal = 60 í100 /min

Regular rhythm
:
Estimate the rate by counting the number of big squares between successive R waves,
and dividing this number
R–R into 300. of: 1 square corresponds to a
interval
heartrate of 300/min 2 squares 150/min 3
squares 100/min 4 squares 75/min 5 squares
60/min 6 squares 50/min

Rate may also be determined by dividing number of small squares between R waves into 1500
Irregular rhythm:
Count the number of QRS complexes in 50 big squares and multiply your answer by 6 (5 big
squares = 1 second, 50 big squares = 10 seconds)

3. Rhythm
Sinus
Rhythm ⁄
\
Non-sinus

Is the patient in normal sinus rhythm?

In normal sinus rhythm the following pertain:

Ɠ The sinus node is the pacemaker of the heart
Because of the anatomical position of the SA node in relation to the AV node, in sinus
rhythm, the P wave is always +ve in Std II, and ņve in aVR. This is because the P wave axis
is directed towards the +ve pole of Std II, and away from aVR.
Ɠ Each P wave is followed by a QRS complex
Each atrial depolarisation wave is conducted through the AV node and results in
depolarisation of the ventricles.

Ɠ The PR interval in a particular lead is constant (the PR interval may vary slightly from lead to
lead)
In sinus rhythm, conduction through the AV node occurs at a normal, constant rate.
In normal sinus rhythm, the heart rate varies with the phases of respiration, so-called sinus
arrhythmia, the rate increasing with inspiration and slowing down on expiration.

If the patient i snot in normal sinus rhythm:

Either the SA node is still functioning as the cardiac pacemaker, but there is a partial or
complete block to transmission of the depolarisation wave to the ventricles at the level of the
AV node (evidence of SA node firing in the form of regular P waves is present)
or
An ectopic focus in atria, AV node or ventricles has taken over the function of cardiac
pacemaker and over-ridden the SA node. This may be for a very brief period (e.g. atrial or
ventricular ectopic beats) or for longer periods e.g. atrial fibrillation.

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If an ectopic rhythm is evident:
ƒ Are the QRS complexes narrow or wide?
ƒ Is the rhythm regular or irregular?
Width (duration) of QRS complexes
Is the rhythm originating in the atria, the AV nodal tissue or the ventricles?
The QRS complexes are usually narrow when the ventricles are being activated along the
normal pathway – along the bundle branches – so will be narrow when an ectopic focus is
situated in atrial or nodal tissue.
If the ectopic focus is in the ventricles, the complexes generated will be wider than normal, as
the ventricular tissue is activated from myocyte to myocyte, rather than via the specialised
conduction tissue, so the ventricular activation takes longer.

(Arhrryhthymthsm oriiagsin watiitnhg nina trhreo awtr iQa RoSr A cVo nmopdalel xtiessu: e)

1. Sinus arrhythmia irregular

2. Sinus rhythm with AV block

First degree regular
Second degree (Mobitz I) irregular
Second degree (Mobitz I) irregular
Third degree (nodal escape) regular

3. Ectopic atrial or nodal rhythms

Atrial/nodal ectopic beats irregular
Supraventricular tachycardias regular
Atrial flutter regular
Atrial fibrillation irregular

Arrhythmias with wide QRS complexes:

(rhythms originating in the ventricles)
Ventricular ectopic beats irregular
Ventricular tachycardia regular
Ventricular flutter regular
Ventricular fibrillation` irregular
Third degree AV block (ventricular escape) regular

In summary, there are three causes of an irregular rhythm (sinus arrhythmia and sick
sinus syndrome excluded)
1. Ectopic beats (atrial, nodal or ventricular)
2. Second degree AV block, usually Mobitz I
3. Atrial or ventricular fibrillation

Escape rhythms

These occur in response to a nodal block, which necessitates that a focus distal to the block
takes over the function of pacemaker for the heart.
SA node block ĺ atrial or AV nodal escape rhythm (AV nodal rate = 40 – 60/min)
AV node block ĺ ventricular escape rhythm (Idioventricular rate = 30 - 40/min) if block low
down in AV nodal tissue; AV nodal escape rhythm if block high up in AV node.

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4. Axis
The normal axis of the heart lies between í29 degrees and +100 degrees.

To determine the axis, the standard leads are used as per table below (blue shaded areas)

Std I Std II Std III

Ÿ
Normal Ÿ Ÿ
or
ź

LAD ź
Ÿ ź

RAD
ź Ÿ Ÿ

(occź)
Extreme
Ÿ
ź or
ź
ź

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Causes of left axis deviation
(ņ30 º to ņ90 º)

1. Marked left ventricular

hypertrophy 2. Left anterior
hemiblock
3. Inferior MI
4. Pregnancy
5. Normal variant

Causes of right axis deviation

(+100 º to +180 º)
1. Right ventricular hypertrophy
2. Left posterior hemiblock
3. Lateral MI
4. Acute pulmonary embolism
5. Emphysema
6. Dextrocardia

7. Spurious (Left & right arms interchanged)

8 Normal variant

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5. P wave

The P wave reflects depolarisation of the atria. This wave is usually a single deflection, and is a
composite wave representing depolarisation of both right and left atria. When conduction through the
atria is slow, the P wave may be seen as a series of two waves, the first being due to depolarisation of
the right atrium, the second caused by left atrial depolarisation occurring shortly thereafter.

Height and shape of P wave

A normal P wave is < 3mm x 3mm in height and width.
Right atrial hypertrophy (“P pulmonale”) = P wave 3 mm in height in limb leads (often best seen
in Std lead II)
Left atrial hypertrophy (“P mitrale”) = P wave 3 mm in width. The P mitrale may have a humped
or bifid shape.
In left atrial hypertrophy, the P wave in lead V1 may be biphasic, with a wide or deep –ve
component 1mm

Atrial enlargementA. ,Peaked narrow P waves characteristic of right atrial enlargement.

B,Wide bifid M-shaped P waves typical of left atrial enlargement

Vector of P wave
Inverted: aVR

Upright: I
II
aVF
V4 – V6
Upright/biphasic/inverted: V1 – V3
III
aVL

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6. PR Interval
The PR interval comprises depolarisation of the atria followed by conduction of the
wave of depolarisation through the AV nodal tissue to the top of the interventricular
septum. It is measured from beginning of the P wave to the beginning of the QRS
complex. Normal = 0.12 – 0.2 sec (3 – 5 small squares)
>0.2 sec = first degree heart block

Measurement of the PR interval

7. PR Segment
The PR segment reflects the time taken for transmission of the wave of depolarisation from
atria to ventricles via the AV node and bundle of His.
The PR segment is normally isoelectric. Pericarditis causes depression of the PR segment

Acute pericarditis is often characterised by two apparent injury currents, one atrial, the other
ventricular. The atrial injury current vector produces PR depression. The ventricular injury current
is associated with ST elevation.

QRS Complex
The QRS complex reflects depolarisation of the ventricles. Four features of the QRS complex
need to be assessed:
· Q waves
· Duration
· Voltage
· Configuration
8. Pathological Q waves

Definition: A pathological Q wave is >25% the height of the ensuing wave (from tip of Q to
peak of R). Sometimes the pathological Q wave is not deep but wider than normal
(>0.04sec in duration)

Example of a pathological Q wave in Std III. Note that the depth of the Q wave is > 25% the total height of the
complex, from tip of Q to peak of R.

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9. Duration

Normal duration is 0.10sec (2½ small squares)

10. Voltage

Criteria for normal voltage of left ventricle

Ɠ Limb leads (from top of R to bottom of 10 – 15 mm
S): Ɠ V leads: S in V1/V2 + R in V5/V6: 60 mm if <30 years
40 mm if 30-40 years
35 mm if >40 years
Ɠ Std I < 15 mm < 11 mm
Ɠ aVL

Criteria for normal voltage of right ventricle

Ɠ V1: r < S,
Ɠ Axis No right axis deviation

11. Configuration

ƕ Presence of abnormal waves:

Delta waves of Wolff-Parkinson-White syndrome
J waves of hypothermia
R waves too big in V1 (R>s) or
R waves too small in V3 (r < 3mm)
ƕ Presence of VPBs

Ventricular premature beat (VPB) showing distortion of the QRS and T wave inversion, absence of
P wave and compensatory pause before next sinus beat appears.

12. ST Segment

The ST segment commences at the J point (the junction of the ST segment and the QRS
complex) and extends to the beginning of the T wave. Should be isoelectric as there is no
voltage difference between areas of the ventricles in this phase of the ECG.

Lead V5.
1 = PQ junction that serves as the baseline reference
2 = J point
3 = ST segment
In this example, slight ST depression is present.(2 should be at same level as 1)

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13. T wave

The T wave represents ventricular repolarisation.

Vector

Its vector is often the same as the preceding QRS

complex. Always inverted in aVR
Upright or inverted in V1,V2 (in young people), Std III
Upright in all other leads.

Height

Its height is dependent on the height of the preceding QRS complex, but as a rough guide,
should be 5 mm in limb leads and 10mm in chest leads.

14. QT Interval
Encompasses ventricular de- & repolarisation. It is measured from beginning of QRS to end of T wave.
The QT interval is dependent on heart rate, decreasing as rate increases, and becoming longer as rate
slows. As a rough guide, the QT interval should normally be < half the R-R interval.
Corrected QT is the QT calculated for a heart rate of 60 bpm.
QTc = QT/¥R-R (seconds)

Corrected QT in males is 0.43 sec, in females 0.45 sec.

15. U wave
The U wave is a small wave ( 25% the height of the T wave) which follows the T wave and which is
thought to represent repolarisation of the Purkinje fibers. It is often only visible at slow heart rates, and
is most prominent in the right sided chest leads.
.

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DIRECTION of P and T WAVES
The P wave
< 0.12 sec ( < 3 small squares)
3mm height ( 3 small squares)
Inverted in aVR (all deflections are always negative in this lead)
Upright/biphasic/inverted V1 – V3, III, aVL
Upright I, II, aVF, V4 – V6

The T wave

<5 mm height in limb leads

<10 mm in praecordial leads

Inverted in aVR

Upright or inverted in V1, V2 (young people), III

Upright in all other leads.

Easy way to remember: in Leads V1 and V2

ƒ P and T waves may be upright or inverted (especially in young people)

ƒ ĹST segment may be a normal variant (<3mm) - “early repolarisation” pattern

ƒ ĻST segment may be a normal variant (<1mm)

*Important always to take note of the history, and to compare current ECG with previous ECGs. If ST
deviation from isoelectric line is not present in previous ECGs, the elevation or depression is likely to be
significant.
Pathological T waves

Tall T waves
(>10 mm in V leads / >5mm in limb leads)
ƕ Ischaemic causes: · Acute transmural MI - “hyperacute T waves”

· Coronary artery spasm - Prinzmetal’s Angina / Cocaine

ƕ Non- Ischaemic causes: · Hyperkalaemia

· Acute pericarditis

Inverted T waves

Myocardial Cardiomyopathy
ischaemia/infarction (CMO) Digoxin
Ventricular hypertrophy CVA
BBB
Pulmonary embolism
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19
 ECG Differential Diagnoses
P waves
Tall P waves
Ɠ
P wave 3 mm in height in limb leads (“P pulmonale”)
ƒ Right atrial hypertrophy

Ɠ Wide P waves
P wave 3 mm in width in limb leads (“P mitrale”)
ƒ Left atrial hypertrophy
ƒ Slow atrial conduction due to IHD

Ɠ P wave with altered configuration

P wave in sinus rhythm is always íve in aVR, +ve in Std II.
If pacemaker of the heart is a focus low down in the atrium or in AV nodal tissue, P wave
will be +ve in aVR and íve in Std II
The P wave of an atrial ectopic beat close to the SA node has a slightly different configuration from
the sinus P wave.

PR Duration

Short PR
Accessory pathways such as W-P-W
Nodal tachycardia (atria depolarised just before ventricles)
Ectopic atrial rhythm (focus close to AV node)
Long PR
Elderly
Drugs “ABCD” e.g. Adenosine, Beta blockers, Calcium channel blockers, Digoxin
Myocarditis
IHD especially involvement of RCA which supplies AV node in 90% of individuals. AV block is
common in inferior myocardial infarction, when caused by RCA occlusion
QRS Complex

Pathological Q waves

Normal variant in aVR, aVL, aVF, Std III, V1

Myocardial infarction (transmural)
Left ventricular hypertrophy Absent r waves V1 – V3 ĺ QS waves in these leads
Right ventricular hypertrophy Poor/ reversed r wave progression may ĺ QS waves in right-
sided chest leads
Left bundle branch block. Absent r waves V1 – V3 ĺ QS waves in these leads
HOCM Septal hypertrophy ĺ deep Q waves in lateral chest leads (Leads
V5 & V6)
Widened QRS complex (> 0.10sec)

Bundle branch block (left or right)

Non-specific intraventricular conduction delay
Ventricular beats
Hyperkalaemia
Drugs e.g. tricyclics
W-P-W

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Low voltage QRS complexes
(<5mm limb leads, <10mm chest leads)
Spurious (ECG calibration altered to 5mm/mV)
COPD
Obesity
Pericardial effusion

Infiltration of the myocardium e.g.

hypothyroidism/amyloid Extensive myocardial
infarction

R wave > s wave in Lead V1

Posterior MI (transmural)
Right ventricular hypertrophy
Right bundle branch block
W-P-W

R wave in Lead V3 < 3 mm (“poor R wave progression”)

Anteroseptal MI
LVH/RVH
LBBB
COPD

ST segment elevation

Transmural myocardial infarction (STEMI)

Coronary artery spasm: Prinzmetal’s angina
Cocaine
Ventricular aneurysm
Normal variant (V1 – V2, 3 mm)
LVH (V1 – V3)
LBBB (V1 – V3)
Acute pericarditis
Acute myocarditis
Hyperkalaemia

ST segment depression
Myocardial ischaemia: · angina pectoris
· sub-endocardial MI
Reciprocal change in acute transmural myocardial
infarction Normal variant (only in V1 – V2, < 1 mm)
Left ventricular hypertrophy (in left chest leads, V5-V6)
Right ventricular hypertrophy (in right chest leads, V1-
V2) LBBB (V5 –V6)
RBBB (V1-V2)
Digoxin
Hypokalaemia

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T wave abnormalities

Tall T waves (> 10 mm in V leads/> 5 mm in limb leads)

Acute transmural MI
Coronary artery spasm
Acute pericarditis
Hyperkalaemia

Inverted T waves

Myocardial ischaemia/infarction
Ventricular hypertrophy
BBB
CMO
Digoxin
CVA
Acute pulmonary embolism (Leads V1 –
V4) (Hypokalaemia ĺT wave flattening)

QT Interval

Short QT Long QT
Congenital Congenital
Drugs e.g. digoxin Drugs e.g. Amiodarone
Erythromycin
Hyperkalaemia Hypokalaemia
Hypercalcaemia Hypocalcaemia
Hyperthermia Hypothermia
Acidosis IHD
Myocarditis
Head injury/Sub-arachnoid Hx/Vasovagal
U Waves

Prominent U waves
Hypokalaemia
Antiarrhythmic drugs e.g. Amiodarone
LVH
Sub-arachnoid Hx
Inverted U waves
Myocardial ischaemia

Axis Deviation

LAD RAD
LVH RVH
fascicular
Left anterior Left posterior fascicular block
block Inferior MI Lateral MI
Pregnancy Acute pulmonary embolism
Normal variant COPD
Dextrocardia
Normal variant
Spurious (arm electrodes interchanged)

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 Classification of arrhythmias
Arrhythmias arise due either to a disorder of impulse

Ɠ formation

or

Ɠ conduction

Disorders of impulse formation

In addition to the specialised tissue known as the sinu-atrial node (SA node), which normally fills the
role of pacemaker for the heart, all elements of the conducting tissue, such as the atrio- ventricular
node (AV node), bundle branches and Purkinje fibers are capable of performing this pacemaker
function, as well as the cardiac myocytes, which all have inherent rhythmicity – the ability to
generate an impulse de novo.
An arrhythmia is any rhythm which does not fulfil the criteria for normal sinus rhythm (the
impulses originate in the SA node at a rate of 60 -100 times per minute, each impulse is conducted
through the AV node to the ventricles and the time taken for this to occur is the same for each
impulse generated)
Arrhythmias may therefore arise in the SA node, the atria, the AV node, or the ventricles.

ƒ Sinus node

Sinus arrhythmia

Sinus bradycardia

Sinus tachycardia

ƒ Atria

Atrial extrasystoles

Paroxysmal atrial tachycardia*

Atrial flutter

Atrial fibrillation

ƒ AV node

AV nodal extrasystoles

AV nodal re-entrant tachycardia*

ƒ Ventricles

Ventricular extrasystoles

Ventricular tachycardia

Ventricular flutter

Ventricular fibrillation

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Disorders of impulse conduction

ƒ SA node block

ƒ AV node block First degree

Second degree (Mobitz I or Mobitz II)

Third degree (complete heart block)

ƒ Accessory pathways e.g. Wolff-Parkinson-White syndrome ĺ re-entrant tachycardia *

* Supra-ventricular tachycardias (SVTs)

Escape Rhythms

A focus in the atria, AV node or ventricle will start to generate impulses if the impulse generating
mechanism of the heart fails, and the focus then becomes the pacemaker of the heart for as long as
it is the primary impulse generator. The location of the escape rhythm is dependent on the level of
the defect. These rhythms are termed escape rhythms and provide a safety net for the heart in times
of a block in transmission of the cardiac impulse.
SA node block (caused by, for example, inhibition of the SA node by beta blockers) will result in
an atrial escape rhythm or one originating lower down in the AV node (nodal escape rhythm)
AV node block, if third degree, will result in a nodal escape rhythm if the block is proximal in the
AV nodal tissue (sufficient normal AV nodal tissue distal to the block to generate impulses and
take over pacemaker function)

or

in a ventricular escape rhythm if the block is distal in the AV nodal tissue (no normally
functioning AV nodal tissue to take over the function of pacemaker)

Nodal escape rhythms may be differentiated (for the most part) from ventricular escape rhythms by:

Ɠ Duration of the QRS complexes (narrow, normal appearing QRS complexes in AV nodal escape
rhythms, wide complexes in ventricular escape rhythms, because ventricles being activated from
cell to cell, not along normal efficient conducting pathways, so activation takes longer)

Ɠ Rate of the escape rhythm

AV nodal escape rhythm rate 40 – 60 per minute

Ventricular escape rhythm rate 15 - 40 per minute (however, sometimes accelerated to >40/minute)

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 Arrhythmias affecting the sinus node

Sinus Arrhythmia
In healthy people, especially younger subjects, the SA node does not pace the heart at a perfectly
regular rate. Instead, a slight beat-to–beat variation is present. When this variability is more
accentuated, the term sinus arrhythmia is used.
The most common cause of sinus arrhythmia is respiration. Respiratory sinus arrhythmia is a
normal finding and may be quite marked particularly in children and young adults. The heart rate
normally increases with inspiration and decreases with expiration because of changes in vagal tone
that occur during the different phases of respiration.

Respiratory sinus arrhythmia.

Sinus bradycardia
With sinus bradycardia, sinus rhythm is present; the heart rate is less than 60 beats/min.

This arrhythmia commonly occurs in the following conditions:

ƒ Normal variant (Many people have a resting pulse rate of less than 60
beats/min, and trained athletes may have a resting or sleeping pulse rate as
low as 35 beats/min.)
ƒ Drugs that Ɠ increase vagal tone (e.g., digitalis)
Ɠ decrease sympathetic tone (e.g., beta blockers)
Ɠ calcium channel blockers
ƒ Hypothyroidism
ƒ Hyperkalaemia
ƒ Sick sinus syndrome (Some patients, particularly elderly ones, have marked
sinus bradycardia without obvious cause, probably from degenerative disease
of the SA node or surrounding tissue.)
ƒ Sleep apnoea syndromes
ƒ Carotid sinus hypersensitivity
ƒ Vasovagal reactions

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Sinus Tachycardia

In general, sinus tachycardia occurs with any condition that produces an increase in sympathetic
tone or a decrease in vagal tone.
(young)
Rate 100 – 200 bpm
(elderly
100>70–years)
150 bpm

The following conditions are commonly associated with sinus tachycardia:

ƒ Anxiety, excitement, exertion, and pain

ƒ Drugs that increase sympathetic tone (e.g., epinephrine, dopamine, tricyclic antidepressants and
cocaine)
ƒ Drugs that block vagal tone (e.g., atropine)
ƒ Fever, many infections, and septic shock
ƒ Congestive heart failure (CHF)
ƒ Pulmonary embolism
Sinus tachycardia is one of the most common arrhythmias which occurs in acute pulmonary
embolism.
ƒ Acute myocardial infarction; sinus tachycardia generally a bad prognostic sign and implies
extensive heart damage.
ƒ Hyperthyroidism (sinus tachycardia at rest may be an important diagnostic clue)
ƒ Phaeochromocytoma
ƒ Intravascular volume loss because of bleeding, vomiting, diarrhoea, acute pancreatitis,
dehydration.
ƒ Alcohol intoxication or withdrawal

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 Ectopic arrhythmias originating above the ventricles

• Atrial premature beats

• Supraventricular tachycardias
• Atrial Flutter
• Atrial Fibrillation
A trial premature beats (APBs)

An ectopic focusinleftorrightatriumdischargesanddepolarisestheatriabeforethesinus node was d ue

tofire again.

Aetiology

Normal hearts (APBs are the most common arrhythmia)

E motional stress
Caffeine excess
Drugs e.g. those used for asthma, such as epinephrine, aminophylline
Hyperthyroidism
Structural heart disease e.g. valvular lesions

The fourth complex in this recording is an atrial premature complex.

Note the following:

Ɠ configuration of t he ectopic P wave is slightly different from that of the sinus P waves
Ɠ narrow, normal appearing QRS complex follows the ectopic P wave
Ɠ short R-R interval preceding the complex
Ɠ long R-R interval following the complex, the so-called “compensat ory pause”

The APB is distinguishable from a VPB (ve ntricular prem ature complex) by:
ƒ no discernible P wave precedes the VPB
ƒ the VPB differs obviously in configura tion from the normal QRS complexe s, being prolonged in
duration (wide), often bizarre looking and followed by T wave inversion.

The6th, 8th, 9th11th, 12 thcomplexe a rs e VPBs ; afte r th e 13

thcomplex
hascommenced.
(normal QRS) an episode of V T

27
Supraventricular tachycardias Rate 250 bpm

• Acotrnisael ctauctihvyecAaPrBdsia) –( P3 wave before QRS (usually +ve in Std II) or buried in
preceding T wave
• Nodal
– P wavere-entrant tachycardia
often hidden in QRS, may be just before/after QRS, when it
will be seen to be –ve in Std II (atria and ventricles being depolarised at approximately the same time)
• Bypass tract re-entrant tachycardiaventricles – activated before atria, therefore P wave occurs after
QRS and _ve in Std II

A, Normal sinus rhythm.

B, With atrial tachycardia (AT), a focus (X) outside the sinoatrial node fires off automatically at a rapid rate.

C, With atrioventricular (AV) nodal reentrant tachycardia (AVNRT), the cardiac stimulus originates as a wave
of excitation that spins around the AV nodal (junctional) area. As a result, retrograde P waves may be buried
in the QRS or appear immediately before or just after the QRS complex (arrows) because of nearly
simultaneous activation of the atria and ventricles.
D, A similar type of reentrant (circus-movement) mechanism may occur with a bypass tract (BT) of the type
found in Wolff-Parkinson-White syndrome (see ). This mechanism is referred to as atrioventricular re-entrant
tachycardia (AVRT). Note the negative P wave (arrow) in lead II, somewhat after the QRS complex.

Paroxysmal supraventricular tachycardia (PSVT) treated with carotid sinus massage. The first 14 beats in
this rhythm strip show the regular tachyarrhythmia with a rate of about 140 beats/min and no visible P
waves.

28
Atrial 250
Rate: Flutter
– 350 per minute (average 300)
Re-entrant tachycardia travelling anti-clockwise in right atrium (80%), clockwise (20%). Route is
around the tricuspid valve, inbetween the vena caval orifices.
Seen as a sawtooth appearance in inferior leads.
A regular atrial tachycardia and therefore usually a regular ventricular rhythm as well; sometimes if
there is impairment of conduction through the AV node by disease or drugs, the ventricular response
will be irregular depending on how variable the atrio-ventricular block is e.g. varying between 2:1, 3:1,
4:1 block etc.

Causes:
Usually occurs only in a diseased heart: Mitral valve disease
Ischaemic heart disease
Cardiomyopathy
Hypertension
Or, secondary to: Chronic obstructive pulmonary disease (COPD)
Pulmonary embolism
As a complication of cardiac surgery
Atrial rate often 300 pm, with a physiological AV block ĺ 2:1 conduction, so ventricular rate = 150
bpm. Conduction block may increase to 3:1 ĺ ventricular rate = 100 bpm.; 4:1 ĺ ventricular rate = 75
bpm. (AV node cannot normally conduct impulses faster than 200 per minute)

Treatment:
1. Anticoagulation
2. Slow conduction through AV node with ȕ blocker, Calcium channel blocker or Digoxin.
( ȕ blockers inhibit sympathetic tone of AV node, Digoxin enhances parasympathetic tone of AV node, Ca
channel blockers directly inhibit impulse conduction by impairing cellular entry of Calcium ions)
3. Antiarrhythmic agents, such as Amiodarone
4. DC cardioversion
5. Radiofrequency ablation of tract
6. Atrial pacemaker

The arrows are directed at the flutter waves; this patient has a physiological 2:1 AV block (every 2nd flutter wave is blocked
at the AV node, as it is still in its refractory period, having just conducted the previous flutter wave to the ventricles)

Comparison of mechanisms of atrial flutter and atrial fibrillation (AF). Atrial flutter is typically due to a large
reentrant wave originating in the right atrium. With typical atrial flutter, the wave spreads in counterclockwise
direction. AF is attributed to either multiple reentrant wavelets and/or to multiple sites of atrial automaticity.
29
Atrial Fibrillation

Atrial Rate: 350 – 600 per minute

Ventricular Rate: 110 – 180 per minute

Caused by multiple re-entry circuits or multiple ectopic foci of atrial automaticity.

This is one of the most common arrhythmias, the incidence increasing with age.
Incidence
0.9% overall
4% >65 years
9% >80 years
Hallmarks: No recognisable P waves, very irregular ventricular response.

Causes
Hypertension (most common cause of AF)
Mitral valve disease
Ischaemic heart disease (AF occurs in 13.7% cases of acute MI)
Cardiomyopathy
Thyrotoxicosis
Chronic obstructive pulmonary disease
Pulmonary embolism
‘ Complication of cardiac surgery
Part of sick sinus syndrome (“tachy-brady” syndrome)
Pericarditis (especially chronic pericarditis)
Obstructive sleep apnoea
Congenital heart defects e.g. ASD
Alcohol - acute or chronic excessive intake; alcohol withdrawal syndrome
Acute hypoxia, hypercarbia, metabolic disturbance
Obesity
“Lone fibrillator” (specific foci of tissue in left atrium usually situated at the ostia of
the pulmonary veins whose discharge ĺ AF)

Treatment:
1. Pharmacological treatment and anticoagulation
2. Direct Current cardioversion.
3. RF ablation of tissue around pulmonary veins, where ectopic foci are often found.
4. Ablation of AV node with insertion of a ventricular pacemaker.
5. Atrial defibrillator

The fibrillation waves are discernible, but no discreet P waves are present. The fibrillation waves are
conducted to the ventricles at random intervals, resulting in irregular production of the QRS complexes.

30
 VENTRICULAR ARRHYTHMIAS

Ventricular Premature Beats (VPBs)

Aetiology
Normal hearts, particularly the elderly
Anxiety
Caffeine excess
Drugs: ƕ Drugs used for asthma e.g. epinephrine, aminophylline
ƕ Digoxin (very commonly seen in digoxin toxicity)
Electrolyte disturbances ƕ ĻK+
ƕ ĻMg++
Lung disease
Hypoxia
Mitral valve prolapse
Other valvular lesions
Hypertension
IHD, particularly acute MI (most common arrhythmia in this situation)

In this rhythm strip, the third complex and the last are VPBs (occurring before the next sinus P wave was due, no
preceding P wave; wide, bizarre appearing complexes, T wave inversion) in the middle is a short run of ventricular
tachycardia.

Ventricular Tachycardia (VT)

VT is defined as a run of three or more consecutive VPBs.

VT may be non-sustained (lasting from three beats to 30 sec) or sustained, lasting >30 sec

Its morphology may be monomorphic or polymorphic, depending on whether consecutive VPBs

have the same or a variable appearance in a single lead.
Sustained VT (VT lasting longer than 30 sec) is usually a life-threatening arrhythmia for two
reasons:
1. Most patients are not able to maintain an adequate blood pressure at very rapid ventricular rates
and become hypotensive.
2. The condition may degenerate into VF, causing cardiac arrest.

Very rapid VT (>300 bpm) with a sine-wave appearance is sometimes referred to as ventricular
flutter. This arrhythmia often leads to cardiac arrest with VF

31
 Causes Sustained VT, (rate 100 – 300/minute) which may lead to syncope or sudden death, rarely

occurs in
patients without underlying structural heart disease. Most patients with this type of arrhythmia have
some basic structural cardiac abnormality, such as:: · prior MI causing a myocardial scar (most
common cause)

· cardiomyopathy

· valvular disease associated with fibrosis

· ventricular enlargement. Treatment

Despite pharmacologic therapy, some patients are at high risk for life-threatening recurrences of
sustained VT or VF. For these patients, a special device called an implantable cardioverter
defibrillator (ICD) has been developed to deliver an internal electric shock directly to the heart
during a life-threatening tachycardia
(According to Australian cardiologists, ICD also may stand for “implantable cardiac device”).

Polymorphic VT (Torsades des pointes)

Occurs with or without a prolonged QT syndrome, for example with acute ischaemia

Ventricular Fibrillation

Aetiology

Heart disease of any type

Acute MI
Drugs Ɠ Digoxin in toxic doses, particularly in presence of ĻK+ or ĻMg+ +
Ɠ Epinephrine
Ɠ Drugs ĺ ĹQT e.g. quinidine, procainamide, erythromycin
Ɠ “Recreactional” drugs e.g cocaine
Preceding ventricular arrhythmias e.g .ventricular premature beats or ventricular tachycardia
Short/long QT interval
Prominent U waves
Non-penetrating blow to the chest
Electric shock/lightning strike
AF occurring in a patient with W-P-W syndrome.

Ventricular tachycardia (VT) and ventricular fibrillation (VF) recorded during the onset of cardiac arrest. The
rapid sine-wave type of VT seen here is sometimes referred to as ventricular flutter.

32
 The conducting system of the heart

Normally, the cardiac stimulus is generated in the sinoatrial (SA) node, which is located in the right atrium
(RA). The stimulus then spreads through the RA and to the left atrium (LA) via an inter-atrial conducting
pathway. It reaches the atrioventricular (AV) node via three inter-nodal pathways and spreads through the AV
node and the bundle of His, which comprise the AV junction. The stimulus then passes into the left and right
ventricles (LV and RV) by way of the two fascicles of the left bundle branch and the right bundle branch,
which are continuations of the bundle of His. Finally, the cardiac stimulus spreads to the ventricular muscle
cells through the Purkinje fibers

LBB = Left bundle branch

LAF = Left anterior fascicle
LPF = Left posterior fascicle

Diagram showing anterior and posterior fascicles of left bundle branch

33
 SINUS ARREST or BLOCK (SA BLOCK)

SA block or arrest can occur in the sick sinus syndrome or be caused by numerousacute factors,
including:
ƒ Hypoxia
ƒ Myocardial ischaemia or infarction
ƒ Hyperkalaemia
ƒ Digitalis toxicity

ƒ Toxic responses to drugs such as beta blockers and calcium channel blockers
ƒ Vagal hyperreactivity (e.g. severe vasovagal episode)

ATRIOVENTRICULAR BLOCK (AV BLOCK)

This is characterised by a delay or interruption in conduction of the atrial impulse through the A – V
conducting system, that is, the A – V node and Bundle of His
There are 3 degrees:

1. First degree A – V block - a delay in conduction

2. Second degree A – V block - intermittent interruption in conduction
3. Third degree A – V block - complete interruption in conduction

First Degree A – V block

Prolongation of the PR interval beyond 0.2 seconds. Conduction from SA node to AV node takes 0.03
sec, the remainder of the PR interval being taken up by conduction through the AV node, Bundle of His,
bundle branches, Purkinje fibres. In first degree block, the delay is usually located in the A-V node.
Causes:

Old age
Ischaemic heart disease
Myocarditis e.g. acute rheumatic carditis
Drugs e.g. digoxin, beta-blockers

P wave precedes each QRS complex but PR interval is > 0.2 sec

34
Second Degree A – V block
Mobitz Type 1 block = Wenckebach phenomenon
Conduction from atria to ventricles becomes progressively more difficult, resulting in
successive prolongation of the PR interval until a block takes place and the impulse fails to be conducted
down to the ventricles. During this pause, the conducting system recovers, and the process starts
again.This type of block is located in the AV node.

This is an example of a 4:3 block (4xP waves to 3xQRS complexes)

Causes:

1. Inferior myocardial infarction

2. Drugs e.g. digitalis, beta blockers, and occasionally calcium channel blockers.
3. Normal individuals with heightened vagal tone.

Although Mobitz type I block can progress to complete heart block, this is uncommon, except in the
setting of acute inferior wall myocardial infarction. Even when it does, however, the heart block is
usually well tolerated because the escape pacemaker usually arises in the proximal His bundle and
provides a stable rhythm. As a result, the presence of Mobitz type I second-degree AV block rarely
mandates aggressive therapy.

Mobitz Type II block

The PR intervals are constant, with some impulses failing to be conducted through the Bundle of His. The
site of the block is located lower down than in the Mobitz type I block and when it progresses to
complete heart block, the new pacemaker is located further down the conducting system, resulting in a
slower, less stable rhythm.
This type of block is always pathological and may proceed to complete heart block, making pacemaker
implantation necessary in this condition.

This is an example of a 3:1 Mobitz II block (only every third P wave is conducted to the ventricles, so 3x P waves to 1x
QRS complex)
Causes:

1. Anteroseptal or inferior myocardial infarction

2. Calcific disorders of the fibrous skeleton of the heart.

35
Third Degree A –V Block
Atrial and ventricular electrical activity occurs independently, with no transmission of impulses from
atria to ventricles.
Causes:

1. Lenegre’s disease - idiopathic degenerative process involving the conducting system

exclusively
2. Lev’s disease - calcific process involving valves and conducting system in the elderly 3.
Ischaemic heart disease
4. Cardiac surgery ĺ interruption of fibers / oedema
5. Digoxin toxicity
6. Infections e.g. Chaga’s disease, tumours
7. Congenital heart disease e.g. ASD, VSD
8. Congenital CHB – an isolated congenital anomaly

Complete heart block with underlying sinus rhythm is c haracterised by independent atrial (P) and ventricular
(QRS complex) activity. The atrial rate is almost always faster than the ventricular rate. The PR intervals are
completely variable. Some sinus P waves fall on the T wave, distorting its shape. Others may fall in th e QRS
complex and be “lost.” Notice that the QRS complexes are of norm al width, indicating that th e ventricles a re
being paced from the atriove ntricular junction (nodal escape rhythm) Compare this exa mple with the
following, which shows complete heart block with wide, very slow QRS complexes because the ventricles
are being paced from below the atrioventricular junction (ventricular escape rhythm).

Thisexampleof complete heartblock

atrial(sinus)rhythm. show saveryslow idiov entricu lar rhyt hm anda f aster independent
* An idioventricular pacemaker maybelocatedin theHis-Purkinje system or the ventricular myocardium.

36
Bundle Branch Block
Left Bundle Branch Block (LBBB)

Causes:

ƕ Hypertensive heart disease (commonest cause)

ƕ Coronary heart disease

ƕ Left-sided valvular lesion (e.g. calcification of the mitral valve, aortic stenosis, or aortic
regurgitation)
ƕ Degenerative changes in the conduction system in the elderly.

ƕ Cardiomyopathy

Often, >1 contributing factor may be identified (e.g., hypertension and coronary artery disease).
LBBB often correlates with Ļleft ventricular function; most patients with LBBB have underlying left
ventricular hypertrophy.
Rarely, normal individuals may have a LBBB pattern without evidence of organic heart disease.

Right Bundle Branch Block (RBBB)

Causes:
RBBB may occur in normal hearts or in conditions that affect the right side of the heart:

ƕ Pulmonary artery hypertension, for example as occurs in COPD

ƕ Coronary artery disease.

ƕ Right-sided valvular lesions such as pulmonary stenosis

ƕ Degenerative changes in the conduction system in the elderly

ƕ Atrial septal defect

ƕ Pulmonary embolism

ƕ Coronary artery bypass graft surgery

ƕ Some normal people have this finding without any underlying heart disorder
In patients with acute anterior wall infarction, a new RBBB may indicate an Ĺrisk of complete heart
block, particularly when the RBBB is associated with left anterior or posterior hemiblock (i.e.a
bifascicular block)

Drugs ĺ bundle branch block

Ɠ Anti-arrhythmic drugs, Class I, such as Na channel blockers · Disopyramide

· Procainamide
· Quinidine
Ɠ Antidepressants (tricyclic)
Ɠ Antipsychotic agents, such as Phenothiazine

37
 Bundle Branch Block

Comparison of typical QRS-T patterns in right bundle branch block (RBBB) and left bundle branch
block (LBBB) with the normal pattern in leads V1 and V6. Note the secondary T wave inversions
(arrows) in leads with an rSRƍ complex with RBBB and in leads with a wide R wave with LBBB.

38
 FASCICULAR BLOCKS

The conducting system of the ventricles can be thought of as being made up of three fascicles:
Ɠ the right bundle
Ɠ the anterior fascicle of the left bundle
Ɠ the posterior fascicle of the left bundle

Hemiblocks (unifascicular blocks) Partial blocks in the left bundle system (left anterior or posterior

fascicular blocks) generally do not

prolong the QRS duration substantially but instead are associated with shifts in the QRS axis (leftward
or rightward, respectively). These are known as hemiblocks (half the left bundle is blocked) or uni-
fascicular blocks. Anterior hemiblock is more common than posterior hemiblock, due to the fact that the
posterior fascicle has a dual blood supply from both left and right coronary arteries, whereas the left
anterior fascicle is supplied solely by the left anterior descending artery.
Bifascicular blocks
Examples of bifascicular block include right bundle branch block and left posterior fascicular block,
right bundle branch block with left anterior fascicular block, and complete left bundle branch block.
Chronic bifascicular block in an asymptomatic individual is associated with a relatively low risk of
progression to high-degree AV heart block. In contrast, new bifascicular block with acute anterior
myocardial infarction carries a much greater risk of complete heart block.
Trifascicular disease
Alternation of right and left bundle branch block is a sign of trifascicular disease. However, the presence of
a prolonged PR interval and bifascicular block does not necessarily indicate trifascicular involvement,
since this combination may arise with AV node disease and bifascicular block.

Intraventricular conduction delays can also be caused by toxic factors which may lead to hemiblocks,
bifascicular blocks or left or right bundle branch blocks, particularly:
hyperkalaemia
or
drugs, such as:
• Sodium channel blockers
Ɠ Disopyramide (Rhythmodan)
Ɠ Quinidine
Ɠ Procainamide
• Tricyclic antidepressants
• Phenothiazines

39
 (= half the left bundle is blocked)
Hemiblocks

Left axis deviation in left anterior hemiblock (LAHB) aka left anterior fascicular block (LAFB)
(A)

(B) Right axis deviation in left posterior hemiblock (LPHB) aka left posterior fascicular block (LPFB)

40
 Bifascicular blocks

A typical right bundle branch block pattern is present (rSRƍ in lead V1 and qRS in lead V6). The limb leads
show marked left axis deviation, consistent with left anterior hemiblock. Thus a bifascicular block involving
the right bundle branch (RBB) and the anterior fascicle of the left bundle branch.

A typical right bundle branch block (RBBB) pattern is evident. The limb leads show right axis deviation
(RAD). The combination of these two findings (in the absence of other more common causes of RAD such
as right ventricular hypertrophy or lateral MI) is consistent with bifascicular block due to left posterior
fascicular block in concert with the RBBB. This elderly patient had severe coronary artery disease.

41
 Ischaemic Heart Disease

Normal coronary artery anatomy

(A) Anterior view of the heart showing the left anterior descending (LAD) and right coronary arteries

(B) Diagrammatic depiction of the three coronary arteries. The dotted lines represent the atrioventricular
(AV) and interventricular grooves posteriorly. The continuous parallel lines represent the same grooves
anteriorly.

Coronary artery areas of supply

Knowledge of the area of myocardium which is perfused by each of the three major coronary arteries is
helpful in determining the site of vascular obstruction when an individual has sustained a myocardial
infarct.
The Left Coronary Artery (LCA) divides into the Left Anterior Descending Artery (LAD) and
Circumflex Artery (LCX), which together perfuse the majority of the left ventricular myocardium.
The LAD supplies the following areas:

Ɠ Anterior wall of LV, apex (V4), lower part of lateral LV (V5, V6) (Diagonal branch)
Ɠ Anterior Ҁ ventricular septum (V1 – V4) (Septal perforator)
The LCX generally only supplies:

Ɠ Left atrium
Ɠ Upper part of the lateral wall of LV (Std I, aVL)
Ɠ Posterior LV (V7 – V9) and inferior LV (Std II, III, aVF) in 15% of individuals

The Right Coronary Artery (RCA) supplies:

Ɠ Right atrium
Ɠ Virtually entire right ventricle (RV) V1, V3R-V6R
Ɠ Posterior ѿ ventricular septum
Ɠ Postero-inferior LV in 85 % individuals

*The coronary vascular supply of the lateral wall of the LV varies – the diagonal branch of LAD supplies a variable amount
of the lower part of the lateral wall; the LCX often supplies the upper part of the lateral wall, but may also supply the
lower part. Occasionally, the RCA may extend right around the back of the heart and contribute to the blood supply of the
lateral wall of LV.

42
Blood supply to conducting system:

SA node RCA 75%, dual 25%

AV node RCA 80%, left 10%, dual 10%

Bundle of his LCA 75%, RCA 10%, dual 15%

Left anterior fascicle LAD

Left posterior fascicle Dual

Right bundle LCA

In summary:

LCA supplies:
Most of LV and left atrium
Conducting system below AV node
Contributes to SA and AV nodes
RCA supplies:

Most of RV and right atrium

Inferior and posterior LV (85% of population)
SA and AV nodes
Contributes to conducting system below AV node

Frequency of occlusion of coronary arteries in ischaemic heart disease:

LAD 40 – 50% (antero-septal/extensive anterior MI)

RCA 30 – 40% (inferior MI, often with posterior wall involvement, and in 40%, RV)
LCX 15 – 20% (anterolateral MI, with postero-inferior involvement in 15%)

43
Location of a myocardial infarct

Myocardial infarctions are generally localised to either

(A) the anterior portion of the left ventricle (LV) or

(B) the inferior (diaphragmatic) or infero-posterior portion of the walls of this chamber.

Unless otherwise specified, the description of a myocardial infarct applies to infarction of an area
of left ventricular myocardium (right ventricular infarction generally only occurs in conjunction
with an inferior MI, caused by proximal occlusion of the RCA).
Isolated posterior infarction is uncommon.

Extent of an infarct

Cross section of the left ventricle showing the difference between a subendocardial infarct, which involves
the inner half of the ventricular wall, and a transmural infarct, which involves the full thickness of the wall.

44
ST segment changes in sub-endocardial and transmural infarction

A With acute subendocardial ischaemia the electrical forces (arrows) responsible for the ST segment are
deviated toward the inner layer of the heart, causing ST depressions in lead V5, which faces the outer
surface of the heart.
B With acute transmural (epicardial) ischaemia, electrical forces (arrows) responsible for the ST segment
are deviated toward the outer layer of the heart, causing ST elevations in the overlying lead.

45
 ST elevation myocardial infarction (STEMI)

The earliest ECG changes seen with an acute transmural infarction usually occur in the ST-T
complex in two sequential phases.
Ɠ The acute phase is marked by the appearance of ST segment elevations and sometimes tall
positive (hyperacute) T waves in the leads which are situated such that they view the area of
infarcted myocardium from its epicardial aspect.

Ɠ The evolving phase occurs hours or days later and is characterised by deep T wave inversions in
the leads that previously showed ST elevations.

Shape of ST segment in STEMI

The ST segment elevation seen with acute MI may have different shapes, including:
· plateau shaped
· dome shaped
· oblique elevation
· resemblance to a tombstone

Terminology

An anterior infarct means that the infarct involves the anterior and/or lateral wall of the left
ventricle
The anatomic location of the infarct determines the leads in which the typical ECG patterns appear.
For example, with an acute anterior wall MI, the ST segment elevations and tall hyperacute T
waves appear in one or more of the anterior leads (chest leads V1 to V6 and limb leads I and aVL).
An inferior infarct indicates involvement of the inferior (diaphragmatic) wall of the left ventricle.

With an inferior wall MI the ST segment elevations and tall hyperacute T waves are seen in inferior
leads II, III, and aVF.

46
 Leads showing ECG changes according to the site of infarction

Standard leads II, III, and aVF (ĹST) inferior right ventricle posterior
posterior
V1, V4R – V6R (ĹST)
antero-septal
V1 – V3 (Prominent R waves and ĻST)
lateral (Std I, aVL upper part lateral wall)
V7 – V9 (Q waves and ĹST) (V5 – V6 lower part lateral wall)
V1 – V4 (loss of r waves, ĹST)

V5 – V6, Std I, aVL

ECG indicators of acute ST elevation myocardial infarction (STEMI)

• Imm ediate

T wave starts to peak, ST segment elevates (ST variable in shape).

• W ithin hours

Q wave starts developing, Ļheight of R wave

• Day 1 – 2
T wave starts to invert, Q wave deepens

• Several days later

ST starts reverting to normal

• Weeks – months later

T wave reverts to normal (occasionally remains inverted)

• Permanent change
Q wave usually persists for the lifetime of the patient

47
ECG patterns seen in acute myocardial infarction according to the site of the infarct

. Acute extensive anterior infarction

A: In the earliest phase of the infarction, tall positive (hyperacute) T waves are seen in leads V2 to V5,
with ST elevation in leads V1 – V5
B: Several hours later, marked ST segment elevation is present in the same leads (current of injury
pattern), and abnormal QS waves are seen in leads in V1 and V2.

cute phase of an inferior wall myocardial infarction: ST elevations and new Q waves.

A,
Evolving phase: deep T wave inversions.

B, C, Resolving phase: partial or complete regression of ST-T changes (and sometimes of Q waves).

In A
and B, notice the reciprocal ST-T changes in the anterior leads (I, aVL, and V2).

48
 Posterior Myocardial Infarction

Posterior MI presents a mirror-image pattern of ECG injury in leads V1 to V3. The acute phase is
characterised by ST segment depression, rather than ST segment elevation. The evolved and
chronic phases show increased R wave amplitude and widening instead of Q waves. Other
causes
of prominent upright anteroseptal forces (tall R waves in V1) include right ventricular (RV)
hypertrophy, Wolff-Parkinson-White syndrome, RBBB and HOCM. New appearance of these
changes or the association with an acute or evolving inferior or lateral MI usually allows the
diagnosis to be made. Extension of the 12 lead ECG to include the posterior leads (V7 – V9) will
reveal the classic ECG changes of infarction, as they view the posterior myocardium from its
epicardial surface.

Posterior infarction. Notice the tall R waves in leads V1 and V2. This patient had a previous inferior infarction (Q waves in
leads II, III, aVF) and probably a lateral infarction as well. Notice reciprocally tall positive T waves in leads V1 and V2.

Lateral Myocardial Infarction

Lateral infarction may occur due to occlusion of the left circumflex artery, or to occlusion of the
left anterior descending artery or its diagonal branch. It may even occur in association with a right
coronary artery occlusion. Extending the ECG to measure posterior leads V7 to V9 increases
sensitivity for detecting posterior wall injury patterns which may accompany a lateral wall MI.

Example of lateral myocardial infarction. Poor R wave progression in the precordial leads. Deep Q waves in V4 to V6, Std I
and aVL with T wave inversion. Slight ST segment elevation in precordial leads.

49
 Acute Posterior Myocardial Infarction

Acute transmural posterior MI

The conventional precordial leads (in particular leads V1 – V3) of the ECG image the posterior wall of
the left ventricle from the anterior perspective of the thorax. Acute infarction of the region manifests
ECG changes that are frequently the reverse of the typical abnormalities of AMI. In this schematic
example, lead V1 reveals ST segment depression with an upright T wave and prominent R wave.
Use of the posterior lead V9, which looks at the epicardial aspect of the posterior wall, (in contrast to
lead V1 which looks at the endocardial aspect of the same area) demonstrates the typical changes of
acute transmural MI , namely ST elevation and a deep Q wave, these being the mirror image of the
changes in lead V1.

50
 Right Ventricular Infarction

Proximal occlusion of the right coronary artery before the acute marginal branch can cause right
ventricular as well as inferior acute MI in about 30% of cases. Because the prognosis and treatment
of inferior acute MI differ in the presence of RV infarction, it is important to make this diagnosis.
The diagnosis is assisted by obtaining right precordial ECG leads, which are routinely indicated for
inferior acute MI. Acute ST segment elevation of at least 1 mm (0.1 mV) in one or more of leads
V4R to V6R and Q or QS waves effectively identify RV infarction.

Right ventricular infarction demonstrated with right-sided precordial leads (RV1 to RV6).The ST
segment elevation of inferior acute myocardial infarction is present, as is the reciprocal ST segment
depression in leads I and aVL. The precordial leads are right-sided chest leads, as might be inferred from
the relatively low voltage. ST segment elevation is noted in leads V3R to V6R, consistent with right
ventricular infarction.

51
Non-ST elevation myocardial infarction (non-STEMI)

ECG indicators of non-Q wave MI (non-STEMI, sub-endocardial MI, non-transmural MI)

ST depression rather than elevation, symmetrical T wave inversion, no Q wave, Ĺtroponin.

If extensive, may see reciprocal ST elevation in lead aVR.

Non–Q wave infarction in a patient who complained of chest pain and also had elevated cardiac enzyme
levels.
Notice the deep, symmetrical T wave inversion in leads I, aVL, and V 2to V6. (Prominent Q waves in III and
aV Frepresent an old inferior wall infarction.)

52
 Angina Pectoris

Example 1

A B

A
. Marked ST depression seen in the ECG from a patient who complained of chest pain while being
examined
B
. Five minutes later, after the patient was given sublingual nitroglycerin, the ST segments have
reverted to normal, with relief of angina.

Example 2

ST seg
ment depression

A. Baseline rhythm strip from the positive exercise test of a patient with coronary artery
disease. B. Notice the marked ST depression with increased heart rate.

53
 Biochemical markers used in the diagnosis of acute coronary syndrome
1 Troponin I or Troponin T
.CK-MB
2C-reactive protein (CRP)
. Brain natriuretic peptide (BNP)
3
Trop.onins
4
Trop.onin is a complex of three protein sub-units, which are attached to the tropomyosin strand in
card iac muscle.
Troponin C (calcium binding) not cardiac specific, also found in skeletal muscle
Troponin T (tropomyosin-binding) also not cardiac muscle specific – rises in MI as well as in renal
failure, pneumonia, PE, liver disease, stroke, carcinomas, CCF.
Troponin I (inhibitory) is sensitive and specific to myocardium.
Troponin level starts to rise 4 – 6 hours after myocardial injury, peak levels attained at 12 – 48 hours and
remains elevated for up to 2 weeks.
Either Troponin T (TpT) or Troponin I (TpI) may be used as a marker
ĹTroponin is a marker for myocardial damage and is a strong predictor for recurrent ischaemic events
CK-MB
Troponin is more sensitive to myocardial damage than is CK-MB, therefore its use has led to Ĺdiagnosis
of MI, compared to when only CK-MB was used as the marker, as those patients with a small area of
myocardial necrosis would have had no CK-MB elevation and so would have been labelled as unstable
angina.
CK may be measured as a total or as the MB fraction. This marker is useful to assist in diagnosis of a
recurrent infarct in the acute setting, when the troponin level may still be elevated from the initial MI.
The CK remains elevated for only ± 48 hours.
C-reactive protein (CRP)
CRP is a marker for inflammation of the vessel wall involved in the occlusion. It has been found to have
the ability to actually increase the size of the infarcted area.
CRP is an independent marker of adverse outcome in the acute coronary syndrome.
Brain natriuretic peptide (BNP)
BNP was so-called because it was first identified in porcine brain, but now known to be formed
predominantly in ventricular muscle. Its level increases rapidly in the first 24 hours post MI, peaking at
12 – 20 hours. There may be a second peak 2-5 days later in an extensive MI.
BNP is a predictor of heart failure and Ĺmortality. Patients with Ĺlevels have double the risk of death
over the subsequent 2 years post MI, compared with patients with no elevation in BNP.
The level of BNP can rise even in unstable angina without myocardial necrosis, and is also a predictor in
these patients of heart failure and death.

Diagnostic criteria for acute MI

ĹTroponin or ĹCK-MB
and
Symptoms of myocardial ischaemia or ECG changes of MI

54
Typical cardiac biomarkers that are used to evaluate patients with STEMI include the MB isoenzyme of CK (CKMB) and
cardiac-specific troponins. (URL=upper reference limit)

Ischaemic Heart Disease - facts and figures

Pathology

50% occlusion of a coronary artery results in angina on effort

50% – 80% occlusion causes angina at rest
> 80% occlusion will result in myocardial infarction
History

Silent myocardial ischaemia (ischaemia which is asymptomatic or not recognised by the individual as an
illness) occurs in 70% of cases of angina and 20% of cases of myocardial infarction. These figures are
higher in diabetics and in the elderly.

ECG

Ɠ In the early stages of a myocardial infarction, > 50% of patients show no diagnostic changes on ECG.
Ultimately, most of these patients develop characteristic ECG changes, but 10% fail to show any ST
changes.
Ɠ The majority of MIs appear to be non-STEMIs; 70% of enzyme proven MIs show no ST elevation or
Q waves on ECG.

Ɠ Of the patients who demise as result of their myocardial infarct, 60% do so before they reach hospital,
the cause most often being ventricular fibrillation.

Poor prognostic features post MI

Clinical Features ECG features Markers

Increased age Anterior location ĹĹBNP
Low systolic BP Hyperacute T waves ĹĹCRP
Tachycardia Marked ST elevation
Pulmonary oedema

55
 Acute Pericarditis
Aetiology

Although there are many causes of acute pericarditis, in most cases the cause is unknown (idiopathic)
or due to viral infection.
Clinical Manifestations

Ch•e st pain
Chest painof acute infectious (viral) pericarditis typically develops in young adults (18 to 30 years)
1 to 2 weeks after a viral illness
The symptoms are sudden and severe with retrosternal or left precordial pain and referral to the
back and trapezius muscle area.
Radiation to the arms may occur. The pain is often pleuritic in nature and may be aggravated
(supine or left lateral decubitus posture) or relieved (upright posture) by changes in posture.
• Fever

Pain may be preceded by low-grade fever.

Physical examination
Ɠ Pericardial friction rub often best heard in the supine or left lateral decubitus posture.
Ɠ Low-grade fever,

Ɠ Sinus tachycardia

Ɠ Atrial ectopy

Ɠ Atrial fibrillation (unusual)

Diagnosis

Electrocardio•g ararep hciocm cmhaonng, ecsonsisting of ST segment elevation and PR segment

depression reflecting atrial involvement. After several days, the ST segments normalise and then
the T waves become inverted. Q wave development does not occur. A pericardial effusion may
occur and then tachycardia, loss of R wave voltage, and electrical alternans also may be seen

Acute pericarditis Note the diffuse ST-T wave changes and PR elevation in lead aVR and PR segment
depression in leads II and aVF and in the precordial leads.

56
The ST segments in acute pericarditis are typically concave in appearance (so-called “saddle-
shaped”) in contrast to the coved appearance of the ST segments in acute MI. However, they may
appear very similar in configuration.
Up to 25% of patients with a transmural MI develop acute pericarditis 2 – 3 days post infarction.

ST segment elevation in acute pericarditis; note PR segment depression & absence of pathological Q
wave

Coved ST segment in acute ST elevation MI; note deep QS wave, isoelectric PR segment.

• Blood tests reflect an inflammatory state, with:

·Ĺ ESR

·Ĺ C-reactive protein level

·Ĺ White cell count.

·Mildly Ĺ creatine kinase MB fraction and Ĺtroponin level in up to half of patients and are thought
to represent epicardial inflammation rather than myocardial necrosis.

57
 Acute Pulmonary Embolism
ECG

˹Sinus Tachycardia (one of the most common ECG findings in this situation)

˹T wave inversion V1–V4 due to right ventricular strain (commonest ECG abnormality in PE)

˹Ventricular ectopic beats

˹Atrial fibrillation

˹Right bundle branch block

˹SIQ3T3

S1 (Deep S wave in Standard Lead I) signifies development of acute right axis deviation due
to sudden increase in right sided pressure and right ventricular dilatation.Deep Q waves and T
wave inversion develop in Standard Lead III - ? rationale for this

Electrocardiogram (ECG) showing SIQ3T3

Massive pulmonary embolism on autopsy. This man died with a large clot burden that plugged the distal lobar arterial
branches, eventually producing nearly complete obstruction to blood flow and subsequent cardiac arrest. This man had
vague respiratory symptoms for 2 weeks, causing him to see a physician who diagnosed bronchitis.

58
 Sudden cardiac death
Definition

Sudden cardiac death is an instant unexpected death which occurs within one hour of an abrupt
change in a person's stable clinical state. The mechanism is generally a ventricular
tachyarrhythmia. The underlying pathology is usually coronary heart disease in middle-aged and
elderly persons.
Especially at risk are individuals who have a residual myocardial scar post MI, particularly if the left
ventricular ejection fraction is severely reduced (to approximately 30%). These patients ideally
should have an implantable cardiac defibrillator inserted.
In children and young athletes the two main causes of sudden death are long QT syndrome and
hypertrophic cardiomyopathy.
Loss of consciousness and family history of sudden cardiac death should encourage the physician
to examine the patient's relatives.

Congenital Long QT Syndrome

Clinical Presentation

There are severe and mild forms. In the severe forms, the affected subjects usually experience
syncope due to ventricular arrhythmias during the first decade of life and sometimes in early
childhood.
These ventricular tachycardias are most often induced by physical exercise or by emotion, but can
also occur at rest. Cardiac arrest can be the first presentation of the disease.
Mild forms can be revealed when the individual, who is an asymptomatic carrier of a genetic
defect, ingests a medication that affects ventricular repolarisation and triggers torsades de pointes
and syncope.

Rhythm strips showing torsade de pointes

There is alternating electrical polarity and periodic twisting of the

points of the QRS complex around the isoelectric line.

Genetic Origin of the disease

The long QT syndrome (LQTS) is inherited as an autosomal dominant condition. Asymptomatic

carriers are numerous, probably around 5 to 10 per 100,000 persons (0.01%).

59
Management

Avoidance of competitive sports.

Parents and siblings of diagnosed individual with LQTS should be examined by a cardiologist.
A list of the contra-indicated drugs should be given to each affected member of the family.
Treatment by beta-blockers at maximum tolerated dose prevents most of the cases of syncope and
sudden death.
Implantation of a pacemaker (in patients who are symptomatic from beta-blocker induced
bradycardia) or implantable defibrillator may be required in high risk cases.

Other Causes of long QT interval

x Drugs e.g. amiodarone, exacerbated by grapefruit

x Cardiac pathology (ischaemia/MI, myocarditis, CCF)
x
x
CNS events (head injury, sub-arachnoid haemorrhage, syncopal
x attack) Hypocalcaemia, hypokalaemia, hypomagnesaemia
x Hypothermia
Hypothyroidism

Hypertrophic Cardiomyopathy (HOCM)

Clinical Presentation

Sudden cardiac death constitutes the most devastating aspect of obstructive and non-obstructive
hypertrophic cardiomyopathy. The diagnosis of hypertrophic cardiomyopathy is usually based on
ECG and echocardiography. Loss of consciousness associated with ventricular tachycardia
identifies patients at very high risk of sudden cardiac death. Of the causes of sudden death in
athletes, HOCM is the cause in approximately 25% of cases.

Genetic Origin of the disease

It is inherited as an autosomal dominant. The prevalence of the disease is 0.2%. Penetrance of the
genetic abnormality is variable, and genetic studies have shown that approximately 20% of
genetically affected adults are healthy carriers without any ECG or echocardiographic abnormality.

Treatment

Drug treatment: Beta blockers, Verapamil, Amiodarone

Surgery: myomectomy – surgical removal of part of the hypertrophied myocardium

Alcohol injection into the septum to sclerose the area

Implantable cardiovertor/defibrillator

ECG features of HOCM (93% of patients with HOCM have ECG abnormalities)

˹Left atrial abnormality, due to Ļventricular compliance and coexistent mitral regurgitation.

˹LVH (tall R waves and LV strain pattern in lateral chest leads)

˹Prominent septal Q waves in the lateral leads (Std I, aVL, V5, V6)

˹Tall, broad R waves in V1

˹AV conduction defects may occur

60
 Effect of electrolyte disturbances on the ECG

Po
tassium

Hyperkalaemia (Serum Potassium lev

el > 4.5 mmol/L)
Rhythm Sinusbradycardia;nodal/ventriculararrhythmias
P waveflattens, may disappear
PR interval prolonged
QRS widens
ST s egment shortens and elevate s
T waves QT tall, pea ked
inter val short (due to short ST segment)

Finall y,the ECG pattern becom es that of a sine wave, and ventricular fibrillation or asystole occur
unlessth eK + level is reducedtimeously.
In short,Pwave flattens andPR interval lengthens; T wave peaks and QT shortens

QRS progressively widens and arrhythmias and AV blocks may occur.

The earliest change with hyperkalaemia is peaking (“tenting”) of the T waves. With progressive increases in
the serum potassium concentration, the QRS complexes widen, the P waves decrease in amplitude and
may disappear, and finally a sine-wave pattern leads to asystole or ventricular fibrillation.

61
Hypokalaemia
(Serum Potassium level < 3.2 mmol/L)

Rhythm atrial/ventricular arrhythmias

P wave prominent
PR interval prolonged
ST segment depressed
T waves flattened, may invert
U waves prominent
QT interval normal, but cannot always be accurately measured, because the T waves and
U waves often merge

ECG leads from a patie nt w ith a mark edly low s erum pota ssium concen tra tion of 2.2m mol/L . No tice the
prominent U waves, with flattened T waves.

62
 Calcium

Hypocalcaemia Normal Hypercalcaemia

Hypocalcaemia prolongs the QT interval by stretching out the ST segment. Hypercalcaemia decreases
the QT interval by shortening the ST segment so that the T wave seems to take off directly from the
end of the QRS complex.

High serum calcium concentrations may lead to coma and death. A short QT interval in a patient with
mental status changes is sometimes the first clue to the diagnosis of hypercalcaemia.
Patients may, however, have clinically significant hypocalcaemia or hypercalcaemia without diagnostic
ECG changes.

63
 DIGOXIN

Digoxin is a cardiac glycoside

Mechanism of Action

• Slows heart rate

In sinus rhythm, slows rate of discharge of SA node. ĺ sinus bradycardia
(ņve chronotropic effect)

• Slows AV conduction
The reason for the use of digoxin in atrial fibrillation is that it slows AV conduction by
increasing vagal activity via an action on the CNS; this ĺ slowing of the ventricular rate.
Even though the atrial dysrhythmia is still present, the slowing of the conduction allows for
increased efficiency of the heart due to increased ventricular filling time.

• ĹForce of Contraction
Digoxin inhibits the Na+/K+ pump. The increased Na+ concentration inside the cardiac
myocyte slows extrusion of Ca++ via the Na+/Ca++ exchange transporter
Increased Ca++ stored in the sarcoplasmic reticulum increases the amount of Ca++ released
in each action potential Æ more powerful contraction
(+ve inotropic effect)

Clinical use of Digoxin

Ɠ To slow rate in AF
Ɠ Treatment of heart failure in patients who remain symptomatic despite optimal use of diuretics and
ACE-inhibitors

The inverted tick appearance of the ST segment and T wave which occurs in individuals who are on treatment
with digoxin. Other characteristic ECG features are a prolonged PR interval and a short QT interval.

64
Digoxin Toxicity

Fatigue, malaise and weakness are common.

Cardiac, gastrointestinal and central nervous systems are affected. Electrolyte disturbances may be
present.
CARDIAC: Most common and often first finding is an increase in premature ventricular complexes.
Almost any dysrhythmia can occur but simultaneous increased automaticity of cardiac tissue and
conduction delay in the AV node should raise suspicion. Findings suggestive of toxicity include:

• Frequent premature ventricular complexes, ventricular bi- and trigeminy

• Bradyarrhythmias
• AV block (Mobitz type 1)
• Atrial tachycardia with AV block
• Junctional tachycardia
• Bidirectional ventricular tachycardia

Ventricular bigeminy caused by digoxin toxicity

Ventricular ectopy is one of the most common signs of digoxin toxicity. The underlying rhythm in
A is atrial fibrillation. In B each normal QRS is followed by a ventricular premature beat.

Bidirectional Ventricular Tachycardia

This digitalis-toxic arrhythmia is a special type of ventricular tachycardia with QRS complexes that alternate
in direction from beat to beat. No P waves are present.

65
 GI:
Anorexia, nausea, vomiting, diarrhoea, abdominal pain.
CNS:
Headache, dizziness, visual disturbance (flashing lights, halos, blurred vision, change in
colour perception, decreased visual acuity), confusion, hallucinations, delirium.
Electrolyte disturbance: Hyperkalaemia is often seen in acute poisoning, due to inhibition of the
Na+:K+ pump (K+ stays in ECF)
Hypokalaemia is more common in chronic toxicity

Treatment of Toxicity

•
Acute toxicity: activated charcoal if within 1 hr of ingestion.
•
Treat electrolyte disturbances: hyperkalaemia (with for example glucose and insulin)
hypokalaemia and hypomagnesaemia.
•Digoxin-specific Fab fragments (Digibind)

•B radycardia and heart block: Atropine, temporary pacemaker if symptomatic

• Ventricular tachycardia: Lidocaine or phenytoin, which decrease ventricular automaticity

without slowing AV node conduction.

A high index of suspicion helpful. To minimise toxicity, digoxin levels should be checked
particularly if there is a change in the patient's condition (e.g., weight loss, worsening renal
function) or an interacting drug is started or stopped.

66
ABGs - Learning Objectives

Essential

9 Accurately recognise the 7 components of an ABG reading:

PH, pCO−2, pO2, HCO3, Base Excess, Anion Gap, p50
9 Be able to calculate the anion gap: Na+ − (Cl− + HCO−3)
9 Understand the role of the three major buffering systems:
1. Extra cellular (HCO3− buffer system)
2. Intracellular (H+ uptake in respiratory acidosis, H+ dissociation from haemoglobin in respiratory
alkalosis)
3. Bone
9 Understand the role of the respiratory system (alteration of respiratory rate & depth) and renal system
(excretion of excess H+ in acidosis or HCO− 3in alkalosis)
9 Be able to accurately interpret a simple ABG:
¾ Accurately recognise an acidotic state based on an ABG reading and whether it is respiratory or
metabolic, using DKA and severe COPD as clinical examples
¾ Accurately recognise an alkalotic state based on an ABG reading and whether it is respiratory or
metabolic, using blood transfusion and pneumonia as clinical examples
¾Accurately recognise a normal anion gap acidosis using diarrhoea as a clinical example
¾ Accurately recognise a high anion gap acidosis using DKA as a clinical example

Important
9
Understand the difference between ABG and VBG

Desirable

9 Understand how the p50 value relates to the Oxygen:Haemoglobin Dissociation curve
9 Understand the physiology of the anion gap

67
 Daily Acid Production
We produce 80 mmol H+ ions per day, which require to be buffered & excreted to maintain acid:base
balance. A small proportion of these H+ ions are derived from our daily intake of ingested acids
(mainly from meat and fish); the majority are produced as by- or end-products of metabolism of
proteins, glucose and fats.
Acids derived predominantly from protein metabolism

2Su4lphuric acid HSO

This is the predominant acid we produce in vivo, making up >50% of the total. It is derived from the
catabolism of sulphur-containing amino acids, such as methionine and cysteine.
Phosphoric Acid H3PO4

This acid is derived from catabolism of phosphorus-containing substances, such as:

▪ oes.gp.h loelcipitihdisnF A
Ph

\
PO4 – choline
/
FA
▪ Nucleic acids e.g. DNA, RNA consisting of nucleotides (Sugar – P – Base)

▪ Adenosine triphosphate (ATP) Adenine-ribose-PO4-PO4-PO4

▪ Hydroxyapatite present in bone & teeth Ca10 (PO4)6OH2

Hippuric Acid Produced as a by-product when Angiotensin I is cleaved to form Angiotensin II

Angiotensin I (10 amino acids)→Angiotensin II (8 amino acids) + Hippuric Acid (2 amino acids)

Uric acid End-product of purine metabolism (adenine & guanine)

Acid derived from glucose metabolism

Lactic Acid

↑Anaerobic glycolysis → accumulation of lactic acid

Glucose
↓
Pyruvate → Lactic Acid
Acids derived from fat metabolism

Fatty Acids (FA) CH3 - CH2 – CH2 …….COOH (basic structure of FA)
Ketone Bodies e.g Acetone CH3 – C – CH3
║
O
Acid derived from carbon dioxide (CO2)

Carbonic Acid CO2 + H2O → H2CO3

68
 ACID-BASE BALANCE

PH is the negative log of H+ concentration (40nmol/L ) in the body

pH = −log 40nmol/L
( = 7.4
As a comparison, an average level of potassium in the blood is 4.0 mmol/L = 4,000,000 nmol/L)

The Henderson-Hasselbalch equation

pH = 6.1 + log HCO3 ¯

PCO2 x 0.03
ratio
Itis the of HCO3 ¯to CO2 which is important, not the actual amounts. The buffering systems, lungs and
kidneys all may affect the ratio.
The pH of the body is kept within normal limits (7.35 − 7.45) by the response of the buffer systems of body
fluids, the respiratory centre and kidneys to changes in acid-base status
•Buffer systems (immediate buffering effect, returning pH to normal)
•Respiratory centre (within minutes/hours) → ∆ in concentration of CO2, by ↑ or ↓ ventilation *
•Renal system (within days) → changes in amounts of HCO3 ¯and H+ excreted in the urine
*The respiratory centre is 1 – 2x as effective as the ECF buffer system

Buffer Systems

· Extracellular ·
Intracellular ·
Bone
ExtracellularBuffer System

The most important buffer system in thee xtracellular fluid is the bicarbonate buffer system:

Carbonic Anhydrase*
↓
CO2 + H2O ↔ H2CO3 ↔ H+ + HCO3 ¯

* zinc-containing enzyme → very rapid conversion of carbon dioxide and water to carbonic acid.

If a strong base is added to the system, the OH ¯combines with carbonic acid to form
H2O + HCO3¯; thus a strong base is buffered to form a weak base, which can then be safely excreted by the
kidneys.
OH ¯+ H2CO3 → H2O + HCO3 ¯
Carbonic acid is a weak acid, that is, it does not readily dissociate to provide H+ ions; the HCO3 ¯in the
system is actually provided by sodium bicarbonate, NaHCO3, which is present in the ECF
Thus:
NaHCO3
↓
Na+ + HCO3 ¯
↓
CO2 + H2O ↔ H2CO3 ↔ H+ + HCO3 ¯
If a strong acid is added to the system, the H+ from the acid combines with bicarbonate (from sodium
bicarbonate) to form carbonic acid, which dissociates to water & carbon dioxide, which is then expired.
In this way, a strong acid is buffered to form a weak acid (carbonic acid).

69
Intracellular Buffer Systems

Iinmtrpaocretlalnutlar buffer systems include:

The Phosphate (PO≡ 4) Buffer System:

H+ + HPO24 ¯→ H2PO4 ¯ H+ + H2PO4 ¯→ H3PO4

Intracellular proteins, including haemoglobin:

H+ + Pr ¯→ HPr H+ +
Hb ¯→ HHb

Haemoglobin is a better buffer when it is in the deoxygenated form; when oxygen attaches to the haem, a
H+ ion is also acquired →the haemoglobin structure becoming an acid (= hydrogen donor)
2,3 DPG + Hb ¯= good buffer
oxygen + HbH = acid
Bone Buffer System

Bone consists of matrix which contains specialised cells (osteoblasts & osteoclasts)

The matrix itself has two components:

•organic - collagen and other proteins in ground substance

•inorganic - hydroxyapatite crystals: Ca10(PO4)6(OH)2

The hydroxyapatite crystals make up two-thirds of the total bone volume; they are extremely small and
consequently have a huge total surface area. The crystals contain a large amount of carbonate (CO-23).
CO2 in bone is in two forms:
1. Bicarbonate (HCO-3)
2. Carbonate (CO2-3).

The bicarbonate makes up a readily exchangeable pool because it is present in the fluid which makes up the
‘hydration shell’ around each of the hydroxyapatite crystals. The carbonate is present in the crystals and its
release requires dissolution of the crystals. This is a much slower process but the amounts of buffer
involved are much larger.
Thus two processes are involved in the bone buffer system: ·Ionic exchange
·Dissolution of bone crystals
Ionic exchange – involves peri-crystallar fluid
Bone can take up H+ in exchange for Na+ and K+ or release HCO- 3
Dissolution of bone crystals:
CO2- or HPO2- 34is released and can buffer H+ ions
In acute metabolic acidosis uptake of H+ by bone in exchange for Na+ and K+can occur rapidly without any
bone breakdown.
In chronic metabolic acidosis, the major buffering mechanism is release of calcium carbonate from bone.
Renal tubular acidosis, uraemia & endstage COPD are associated with longterm acidosis and may result in
osteomalacia/osteoporosis as a result of breakdown of the hydroxyapatite crystals.

70
 Renal response to a change in acid:base status
Each day, 4320 mEq HCO3 ¯are filtered by the glomeruli; normally, almost all is reabsorbed thereby
conserving the primary buffer system in the body.
For each mEq of HCO3 ¯to be reabsorbed, one mEq H+ must be secreted into the tubular lumen to combine
with the HCO3¯anion (bicarbonate must be converted to carbonic acid before it can be absorbed).
Thus 4320mEq H+ need to be secreted each day just to allow the HCO3¯to be reabsorbed; in addition a
further 80 mEq H+ must be secreted to rid the body of H+ ions derived from the non-volatile acids produced
daily by the body’s metabolic processes, e.g. lactate, phosphate, sulphate, acetoacetate & β-hydroxybutyrate.
Therefore, 4400mEq H+ need to be secreted by tubular cells/day. (4320 + 80 mEq/L)
When there is alkalosis (↓ H+ /↑ HCO3 ¯in ECF), the kidneys fail to reabsorb all the filtered HCO3 ¯(because
there is an excess of HCO3 ¯in the lumen compared to H+, all the H+ is used up combining with the
HCO3¯and the remaining HCO3 ¯cannot be absorbed into the tubular cell unless it is converted to H2CO3, so
is lost in the urine.)
Conversely, in acidosis, all the filtered HCO3¯is reabsorbed and new HCO3¯is formed and returns to the ECF,
and buffers the excess H+ ions there.

New HCO3 i¯s generated in the following way:

Excess H+ secreted into the tubular lumen combines with phosphate or ammonia rather than HCO3¯(because all
filtered HCO3¯has been reabsorbed) and is excreted as NaH2PO4 and NH4+; this shifts the bicarbonate buffer
system within the tubular cell to the right, and a new HCO3¯is formed for each H+ buffered in this way.
In the PCT, H+ is transported across the luminal membrane attached to a carrier protein, which it shares with Na+. (As
Na+ enters the cell, H+ passes out into the lumen) The energy for this process is derived from the movement of Na+
ions down the concentration gradient for Na+ which has been formed by the Na:K pump situated in the membrane of 3th
e contralateral side of the tubular cell. Its function is to actively pump Na+ out of the cell and K+ into it, in a ratio of
: 2. This creates a negative charge within the cell, and a fall in Na+ concentration, hence → influx of Na+ ions from the
tubular lumen into the cell.
In DCT and collecting ducts, H+ is actively secreted into the lumen by a specific protein, the energy being supplied by
conversion of ATP → ADP. It is this mechanism which is most effective in acidification of the urine.

There are 3 important buffer systems in the kidney:

1. The bicarbonate system within the tubular cells
2. The phosphate system in the tubular lumen
H+ + NaHPO4 ¯→ NaH2PO4 NaH2PO4 = titratable acidity (TA)
Total acid excretion = (TA + NH+ˉ4) – HCO3
(Phosphate is filtered as the sodium salt (NaHPO4¯) at a rate of 30 – 40 mEq/day)
3. The ammonia buffer system within the tubular cells (in PCT, Loop of Henle and DCT) and in the

tubular lumen (in the collecting ducts), is quantitatively more important than the phosphate buffer system:
H+ + NH→ NH+3 4

In the proximal parts of the nephron, the amino acid, glutamine, is absorbed into the tubular cells
where it is metabolised to produce ammonia (NH) which combines with H+ → NH+34. This is then
secreted → tubular lumen and passes out in the urine.
In the collecting ducts, H+ combines with NH3 in the lumen (NH3 being freely diffusible across the
tubular cell membrane). The NH4+ thus formed, cannot diffuse back into the tubular cell, and passes out in the
urine.

71
72
 Characteristics of Acid-Base Disturbances

Normal PH PCO2 HCO3 ¯

Respiratory acidosis 7.4 40mmHg 24mEq/L
Respiratory alkalosis ↓ ↑↑ ↓↓ ↑ ↓ ↓↓
Metabolic acidosis ↑ ↓↑ ↑↑
Metabolic alkalosis ↓
↑

Acute changes in H+ ion concentration affect theO xygen : Haemoglobin Dissociation Curve
(Bohr effect), acidosis shifting the curve to the right, alkalosis to the left.

K+ and H+ concentrations in ECF parallel each other:

↓K+, ↓H+)
Hypokalaemia is associated with alkalosis (
When hypokalaemia is present, potassium is preferentially reabsorbed in the renal tubules in exchange for
H+, which is then lost in the urine, resulting in metabolic alkalosis; when an individual is alkalotic (that is, the
H+ concentration in the blood is too low) H+ moves from the intra-cellular to the extra-cellular fluid in
exchange for K+, hence resulting in hypokalaemia.
Hyperkalaemia is associated with acidosis (↑K+, ↑H+)
In a situation of acidosis (increased H+ concentration in ECF), intracellular buffering of H+ ions takes place
in exchange for K+, which then accumulates in the ECF.

Predominant ECF ions: Sodium, chloride, bicarbonate

Predominant ICF ions: Potassium, phosphate, proteins, magnesium, sulphate (PPPMS)

H+ and HCO3 ¯can diffuse in and out of cells, but do so slowly.

Definition of Base Excess

The amount of base that requires to be added to or removed from 1L of blood to restore the pH to 7.4 at
a PCO2 of 40 mm Hg
It follows that these measurements are only helpful in ascertaining the metabolic causes of acid-base
reissttuorrbinagn
d ces, since any respiratory contribution to the acid:base disturbance has been removed by
the PCO2 to 40 mmHg.

73
 The Anion Gap

The anion gap is the difference in number between the positively and negatively charged ions used in the
formula below, the cation level (sodium) being greater than the sum of the level of the two anions
(bicarbonate and chloride)

Anion Gap = (Na+) − (HCO3¯+ Cl¯)

If we take average normal values for these ions and calculate the anion gap using this formula, it becomes
clear how the anion gap value is obtained.

Ion Normal range

Sodium 135 – 145 mmol/L
Bicarbonate 22 – 33 mmol/L
Chloride 100 – 110 mmol/L
Anion Gap 4 − 13 mmol/L

Anion Gap = 140 − (25 + 105) mmol/L

= 140 − 130 mmol/L
= 10 mmol/L

There is no real anion gap in the plasma, as the total number of positively and negatively charged ions
balance each other out exactly. It is simply a manmade formula which is helpful to determine the cause of a
metabolic acidosis, as it tells us whether the acidosis has been caused by:
an excess of acid e.g. ketoacids in diabetic ketoacidosis:
◦
or
a loss of bicarbonate from the body e.g. diarrhoea
◦

74
Metabolic acidosis caused by excess of acid
(High anion gap metabolic acidosis)
Diabetic ketoacidosis (DKA) is an example of a high anion gap metabolic acidosis.
When, for example, acetoacetic acid accumulates in DKA, it donates its hydrogen ion to the plasma, and
the anion (acetoacetate) is formed; the hydrogen ion is buffered by plasma bicarbonate.
Figure: Structure of acetoacetic acid

O
║
CH3 – C – CH2 – COOH
acetoacetic acid
↓
O
║
CH– C – CH – COO‾ + H+ 3 2
acetoacetate anion

Thus the plasma bicarbonate level falls. For each hydrogen ion buffered, there is a corresponding fall in
bicarbonate level, and the loss of this negatively charged anion from the plasma is replaced by the anion of the
acid donating the hydrogen ion, in this case, acetoacetate, thus maintaining electrical neutrality in the plasma.
The HCO3 ¯level falls in both a high anion gap metabolic acidosis and a normal anion gap metabolic acidosis;
in a high anion gap metabolic acidosis, this is due to the plasma bicarbonate being consumed as a buffer for the
added acid – there is no change in the levels of the other two measured ions, that is, the sodium or the chloride
ions.
e.g. 140 − (15 + 105)
= 140 − 120 = 20 mmol/L

Metabolic acidosis caused by loss of bicarbonate

(Normal anion gap metabolic acidosis)
In a normal anion gap metabolic acidosis, the bicarbonate level falls, not because it is being used as a buffer
for the added acid, but because it is being lost from the body, either from the GIT as in diarrhoea, or via the
kidney in renal tubular acidosis or Addison’s disease. There is no added acid to the plasma to provide a mmol
of anion for each mmol fall in bicarbonate, so the loss of anion (bicarbonate) must be balanced by an increase
in the plasma chloride level, resulting in the so-called “hyperchloraemic metabolic acidosis”
Because chloride is one of the ions used in the formula, and as its level increases as the bicarbonate level
decreases, the total number of anions in the formula remains the same.
e.g. 140 − (15 + 115)
140 − 130
10 mmol/L

75
Causes of a high anion gap acidosis
“KUSMAL”
(Kussmaul breathing = deep, sighing respiration of acidosis)
Adolf Kussmaul, German physician,
19th century.
UKe acidosis
Kto
Uraemia
MSa ylic acid
Slic
Methanol
A
LAntifreeze (ethylene glycol)
Lactic acid

Ketoacido: sAicsetone, acetoacetic, beta-hydroxybutyric acids

eg DKA
Starvation
Catabolism of alcohol → beta-hydroxybutyric acid

Uraemia: In CKD, the kidneys are unable to adequately excrete the daily acid load
produced by metabolic processes

SalicylateSsa licylic acid, lactic acid and ketones in 25% of cases

Methanol
Formic acid (used in drink spiking)
Antifreeze
(EthyleneO gxlaylcico la) nd glycolic acids
Lactic Acidosis
: Poor perfusion e.g. shock
Alcoholism (↑NADH → formation of lactic acid from pyruvate)
Iatrogenic (Phenformin)
Bowel ischaemia / infarction

Causes of a normal anion gap acidosis

Diarrhoea (commonest cause of metabolic acidosis overall)

Due to loss of bicarbonate from the GIT.
↓Tubular secretion of H+ &/or ↑renal loss of HCO3 ¯
Renal tubular acidosis (RTA)

Addison’s Disease ↓Mineralocorticoid effect →↑renal loss of Na+ (and

water), ↓tubular secretion of H+, ↑renal loss of HCO3 ¯

76
Causes of Metabolic Alkalosis

(An uncommon acid:base disturbance)

1. Loss of acid
From the stomach ▫ vomiting gastric contents/nasogastric suction
From the kidneys ▫ ↑Aldosterone

e.g. Diuretics
Cushings syndrome
Conn’s syndrome
Excessive licorice ingestion
Corticosteroid treatment

▫ Hypokalaemia→ preferential absorption of K+ in tubules in exchange for H+

2. Addition of alkali ▫ IV Bicarbonate, used in the treatment of severe metabolic acidosis

▫ Citrate in a large blood transfusion

(Aldosterone → Na+ reabsorption in exchange for H+ and K+ → hypokalaemic metabolic alkalosis)

Causes of Respiratory Acidosis

· Lung disease resulting in:

▫ inadequate transfer of CO2 across respiratory membrane e.g. COPD, late stage asthma
▫ obstruction to expiration e.g. laryngo-tracheo-bronchitis, foreign body, strangulation
· ↓Chest wall movement e.g. intercostal muscle paralysis as in Guillain-Barre syndrome, quadriplegia,
Myasthenia gravis; phrenic nerve palsy, ankylosing spondylitis, chest pain e.g. from fractured ribs
· Respiratory centre depression e.g. use of opiates

Causes of Respiratory Alkalosis

Any cause of tachypnoea, such as:

· anxiety
· pneumonia
· hepatic failure (ammonia & other substances normally metabolised by the liver stimulate the respiratory
centre)
· pregnancy (progesterone stimulates the respiratory centre)
· mechanical ventilation

77
 Buffering in Acid:Base Disturbances

pH = 6.1 + log HCO3‾

PCO2 x 0.03

Buffering means that a strong acid (one which readily donates its H+) is exchanged for a weak one (carbonic
acid) which is much less ready to donate its H+ and instead dissociates into H2O + CO2, which is then
expired. The anion of such an acid then causes an elevation in the anion gap.
If a strong alkali is added to the body, it is converted to a weak one (bicarbonate) which can then be readily
excreted by the kidneys.
Buffering of metabolic acid:base disturbances takes place partially in the ECF, (bicarbonate buffer system),
partially in the intracellular compartment (phosphate, protein buffers), and partially by the bone buffer system.

•Metabolic Acidosis
Excess metabolic acid (high anion gap acidosis) :
◦ ECF buffering:

H+ donated by the acid is buffered by bicarbonate in the ECF:

H+
+
↑CO + ↑H+22O ← ↑H2CO3 ← HCO3‾ + H
◦ Respiratory compensation:

The ↑PCO2 and the ↑H+ concentration stimulate the respiratory centre → ↑ventilation rate → ↑CO2 expired
(Kussmaul respiration)
Therefore: ↓↓HCO3‾ (used up in buffering process)
↓PCO2 (compensation)
◦ Renal compensation:

As the excess H+ is excreted, for each ion passing out in the urine, a new bicarbonate ion is formed and
enters the ECF

Loss of bicarbonate (normal anion gap acidosis):

CO+2 + H2O ↔ H2CO3 ↔ ↓HCO3‾ + H

Insufficient HCO+ 3‾ is present in ECF to buffer the daily H+ production → ↑Hconcentration (acidosis)

◦ Chloride level ↑ to maintain electrical neutrality

◦ Respiratory compensation:
The ↑H+ concentration stimulates the chemoreceptors in aorta and carotid artery and the respiratory centre
→ ↑ventilation rate → ↑CO2 expired (Kussmaul respiration)

◦ Renal compensation: As in high anion gap metabolic acidosis

78
•Metabolic Alkalosis

Caused by loss of acid/gain of alkali (bicarbonate or other e.g. citrate)

Loss of acid:

* CA
CO+2 + H2O ↔ H2CO3 ↔ HCO3‾ + ↓H

◦ Respiratory compensation:

The ↓H+ concentration inhibits the respiratory centre → ↓ventilation rate → CO2 retained so equation → right
so H+↑ (and bicarbonate ↑ secondarily)
*CA = carbonic anhydrase

◦ Renal compensation

Too little H+ for reabsorption of all filtered bicarbonate so balance lost in urine → a fall in HCO3‾ in ECF

Addition of alkali other than HCO3‾:

OH‾
+
H2CO3 → ↑HCO3‾ + H2O
◦ ECF buffering
The excess HCO‾ comb+ +3ines with H→ ↓H
Thus, even though the equation will shift to the left, the respiratory centre responds to the fall in H+
concentration by decreasing the respiratory rate. (The respiratory centre is more sensitive to H+ concentration
than it is to PCO2 level)
◦ Respiratory and Renal compensation:

Same as in alkalosis caused by loss of acid

→ retention of CO2
→ loss of HCO3‾ in urine

Addition of bicarbonate:

CO+C+2 H2O ↔ H2O3 ↔ ↑HCO3‾ + H

◦ Compensation: Same as above

79
•Respiratory Acidosis

↑CO +2 +H2O → ↑H2CO3 → ↑HCO3‾ + ↑H

Intracellular buffering:
◦
H+ is buffered intracellularly by haemoglobin, other proteins and PO4≡

Buffering of respiratory acid:base disturbances takes place ± purely intracellularly, predominantly by

haemoglobin. The bicarbonate buffer system is not involved.

Renal compensation:
◦
In the kidneys, once all the bicarbonate has been absorbed, excess H+ is secreted into tubular lumen
(buffered by phosphate and ammonia), and for each H+ secreted, a bicarbonate ion re-enters the
circulation.

•Respiratory Alkalosis

↓CO ++2 H2O → ↓H2CO3 → ↓HCO3‾ + ↓H

Buffering as such does not take place. A fall in the PCO causes the haemoglobin molecule to donate a H+2
ion, which diffuses from inside the red cell into the ECF→ helping to elevate the H+ concentration.
Renal compensation:
◦
At the renal level, there is less H+ available for bicarbonate reabsorption in the tubules → loss of bicarbonate
in urine → ↓HCO3‾ in ECF

80
 P50

Haem portion of haemoglobin

Oxygen attaches to the ferrous (++) iron in the centre of the porphyrin ring structure of haem. (This is a non-
ionic bond) The P50 is the partial pressure of oxygen in the blood when haemoglobin is 50% saturated with
oxygen. When the position of the oxygen:haemoglobin dissociation curve is normal, that is, when the bond
between oxygen and haemoglobin is of normal strength, the P50 value is 24mmHg – 28 mmHg. If the curve is
shifted to the right, this means that the bond is weaker than normal, and that oxygen more readily dissociates
from haemoglobin as it passes through the tissues, and oxygen delivery is therefore improved. In this
situation, the P50 value is > 28mmHg. When the curve is left-shifted, the affinity of haemoglobin and oxygen
is increased (stronger binding) and oxygen delivery at tissue level is therefore decreased. The P50 value is <
24mmHg. As the blood flows past the respiratory membrane the haemoglobin avidly takes up oxygen when
the curve is in the leftward position. In summary, the P50 shows us the position of the curve, and infers the
quality of oxygen delivery to the tissues. Factors which shift the curve to the right do so by exerting a
conformational change in the haemoglobin molecule by binding to the globin chain.This change lessens the
strength of the bond between the iron and oxygen. Factors → right shift Factors → left shift ↑H+ ↓H+ ↑CO2
↓CO2 ↑Temperature ↓Temperature ↑2,3 Diphosphoglycerate (2,3 DPG) ↓2,3 DPG Carbon monoxide Foetal
haemoglobin (Hb F) Methaemoglobinaemia

PO2mmHg

Oxygen-haemoglobin dissociation curve.

The P50 of adult blood is 24 - 28 mmHg. Under basal conditions, mixed venous blood has PO2 of 40 mmHg and oxygen-
haemoglobin saturation of 75%. In arterial blood, these values are 100 mmHg and 97.5%, respectively.

81
The Respiratory Membrane

82
Pulmonary Function Tests – Learning Objectives

Essential

9 Understand what a PFT measures: static lung volumes, spirometry, Flow Volume Loop,
DLCO.
9 Accurately recognise an obstructive pattern using asthma and COPD as clinical
examples
9 Accurately recognise a restrictive pattern using asbestosis as a clinical example
9 Be able to perform spirometry on a patient (Pulmonary lab at Mater; opportunities on
rural term)
9
Accurately identify the major structures visible on a PA and lateral CXR (Diagnostic
Imaging Pathways website)

83
 Static Lung Volumes

Static lung volumes are determined using methods in which airflow velocity does not play a
role. They reflect the elastic properties of the lungs and chest wall.
The sum of two or more lung volumes constitutes a lung capacity.
The subdivisions and capacities are expressed in liters.
Four volumes are measured (tidal volume, inspiratory reserve volume, expiratory reserve
volume, and residual volume). Using these four measurements of volume, four capacities are
calculated

Subdivisions of Lung Volume

Inspired and expired volumes during normal quiet breathing.

Most lung volumes and capacities can be measured by spirometry.
(TLC, FRC, and RV are not determined by spirometry.)
EexRpVi,ratory reserve volume
FfuRn
IinCsCc,tional resid,piratory
ual
Iin rve capacity
volume capacity
Rr eR s
TtoVsVp,iratory reseut,idal volume city

VtCtCal la,ung capa,l capacity T, idal volume

VviL

84
1Ti dal volume (TV) is the volume of air that is inhaled or exhaled with each normal
respiratory cycle.
2 Inspiratory reserve volume (IRV) is the maximal volume of air that can be inhaled after a
normal tidal inhalation.
3 Expiratory reserve volume (ERV) is the maximal volume of air that can be exhaled after a
normal tidal exhalation
4 Residual volume (RV) is the volume of air remaining in the lung at the end of a maximal
expiration.
The RV normally accounts for 25% of total lung capacity (TLC).
In restrictive lung disorders, RV decreases less than the other volumes.
In COPD and asthma, the increase in TLC is due largely to an increase in residual volume.

5 Functional residual capacity (FRC) is the volume of air in the lungs after a normal tidal
exhalation. It is the sum of the ERV and RV.
FRC = 40% of TLC.

6. Inspiratory capacity (IC) is the maximal volume of air that can be inhaled after a normal
tidal exhalation.
IC = sum of TV and IRV.

7. Vital capacity (VC) is the maximum volume of air that can be expired slowly after a full
inspiratory effort.
The subdivisions of the VC include TV, inspiratory reserve volume (IRV), and expiratory
reserve volume (ERV).
VC = IRV+TV+ERV
Also, VC = TLC - RV
8. Total lung capacity (TLC) is the volume of air in the lung at the end of a maximal

inspiration.
TLC may be calculated in one of two ways:
(1) TLC = RV + VC
(2) TLC = FRC + IC.

Forced Vital Capacity, FEV1 and FEF 25% – 75%

Forced vital capacity (FVC)

The FVC is the volume of air expired fowliltohw minagx mimaaxli mfoarlc einspiration.
The VC can be much greater than the FVC in patients with airways obstruction. The FVC
manoeuvre can result in premature closure of terminal airways with resultant air trapping, so
the true RV is not reached.

Forced Expiratory Volume in the first second (FEV1)

The FEV1 is the volume of air expired in the first second of the FVC manoeuvre.
FEV1 = 75-80% of FVC

Forced expiratory flow during the middle half of the FVC (FEF 25% – 75%)
The mean forced expiratory flow during the middle half of the FVC (FEF 25% – 75%) is the
slope of the line that intersects the spirographic tracing at 25% and 75% of the FVC. The FEF
25% - 75% is less effort dependent than the FEV1 and is a more sensitive indicator of small
airways obstruction (airways <2mm in diameter). The line approaches the horizontal due to
prolongation of the expiratory phase in airways obstruction.
85
 Flow Volume Loops
The flow-volume loop is recorded by a spirometer during a forced inspiratory and expiratory
VC manoeuvre. The shape reflects the status of the lung volumes and airways throughout the
respiratory cycle.
Peak expiratory flow rate is sometimes used to estimate degree of airways obstruction, but is
very dependent on patient effort.
The small airways (diameter < 2mm), constitute < 10% of the total airway resistance, but their
surface area is large. Disease affecting primarily the small airways can be extensive, yet not
affect tests such as FEV1.

Expiratory flow rates over the lower 50% of the FVC (i.e. approaching residual volume) are
sensitive indicators of small airways disease, such as early obstructive and interstitial lung
disease.

A: Normal

Inspiratory limb of loop is symmetric and convex. Expiratory limb is linear.

B. Restrictive disease (e.g. sarcoidosis, kyphoscoliosis)

Configuration of loop is narrowed because of Ļlung volumes but shape is basically normal. At
comparable lung volumes, flow rates are normal. (Actually Ĺ because airways held open by
Ĺelastic recoil)

C. COPD, asthma

All flow rates Ļ, but particularly expiratory flow rate is ĻĻ.

Spirometric flow-volume loops.

A is an expiratory flow-volume loop of a nonasthmatic, without airflow limitation.
B to E are expiratory flow-volume loops in asthmatic patients with increasing degrees of airflow limitation (B is
mild; E is severe). Note the “scooped” or concave appearance of the asthmatic expiratory flow-volume loops; with
increasing obstruction, there is greater “scooping.”

86
Spirograms and flow-volume loops

Top Restrictive ventilatory defect

Middle Normal subject

Bottom Obstructive ventilatory defect

87
 Causes of Restrictive Ventilatory Defects

Interstitial Lung Disease

Interstitial pneumonitis
Fibrosis
Pneumoconiosis
Granulomatosis
e.g.
sarcoidosis Pulmonary oedema
Space-Occupying Lesions
Tumour
Cysts

Pleural Diseases
Pneumothorax
Hemothorax
Pleural effusion, empyema
Chest-wall Diseases
Injury
Kyphoscoliosis
Spondylitis
Extrathoracic Conditions
Obesity
Peritonitis
Ascites
Pregnancy

88
 Carbon Monoxide Diffusion Test (DLco)

Whereas spirometry measures the mechanical properties of the lungs, the lung diffusing
capacity test (DLco) measures the ability of the lungs to perform gaseous exchange. The single
breath DLco test requires the patient to inhale a gas consisting of:
Helium 10%
Carbon Monoxide 1000 ppm
Air balance

The inhaled gas is held in the lungs for 10 seconds, during which time the carbon monoxide
diffuses across the respiratory membrane into the pulmonary capillary blood. The helium
does not diffuse.
During exhalation, a portion of the breath representative of alveolar air is collected in a
sample collection system, and the carbon monoxide concentration in this sample is
determined.
The difference between the inspired and expired carbon monoxide concentrations is
calculated, and the diffusing capacity of the lungs determined.
(The difference between the two values = the amount of carbon monoxide which has crossed
from alveolus ĺ pulmonary capillary blood)
Average result for a young healthy male = 17 ml/minute

This test can be of great diagnostic benefit in lung disorders not detectable by spirometry or
chest Xray. The ability of the lungs to pass oxygen from alveoli ĺ pulmonary capillary blood
can be affected by damage to or loss of respiratory membrane as in emphysema, and by
thickening of the membrane by fibrosis or inflammation (interstitial lung disease e.g.
asbestosis)
The DLco test is more sensitive than spirometric measurements and chest Xray for the
detection of interstitial lung disorders.

Causes of Ļ DLco

Interstitial lung disease

Emphysema
Severe anaemia
Smoking

Causes of Ĺ DLco
Polycythaemia
Early left ventricular failure

89
Liver Function Tests and Lipids – learning objectives
Essential

Pre reading
9 Understand the 6 normal functions of the liver: digestive, metabolic, storage, excretion,
9 haemopoiesis, phagocytosis
Identify major anatomical features of the hepatobiliary system: lobes of liver, gall bladder, bile
9
duct and CBD, portal and hepatic veins, hepatic artery
Understand bilirubin metabolism: be able to draw the pathways showing metabolism of haem →
bile etc
9 Important acute phase proteins: ferritin, CRP

In course

9 Accurately interpret Liver Function Tests using clinical examples of viral hepatitis, obstructive
jaundice and fatty liver:
¾Bilirubin (unconjugated vs conjugated)
¾Liver enzymes (GGT, Alk Phos, ALT, AST)
9
Understand the lipid pathways: synthesis of the different lipoproteins (VLDL, LDL, HDL) and
their functions as well as the key enzymes: lipoprotein lipase, hormone sensitive lipase, LCAT,
HMG CoA reductase
9Understand the cause of hyperlipidaemia in Type 2 diabetes
9Understand how urea and albumin levels can be used as a way of assessing liver function
9Be able to list the important secondary (possibly modifiable) causes of hyperlipidaemia: obesity,
hypothyroidism, renal failure, alcohol excess.

9Other important enzymes: CK and LDH whose elevation may not be due primarily to hepatic
pathology, such as:
· LDH: (blood dyscrasias, metastases)
· CK: (MI, CVA, myositis

Important

9 List less common secondary (possibly modifiable) causes of hyperlipidaemia: nephrotic syndrome,
drugs (thiazides, oestrogens, glucocorticoids), cholestatic jaundice.
9Understand other acute phase reactants: fibrinogen, prothrombin, haptoglobin, factor VIII,
platelets, lipoprotein a, complement, caeruloplasmin

90
 FUNCTIONS OF THE LIVER

1. Digestive

Production of bile to aid in digestion and absorption of fats and fat soluble vitamins

2. Metabolic
A most important organ in the metabolism of proteins, carbohydrates and fats.

3. Storage
Vitamin B12 sufficient stores for 1 – 3 years
Vitamin A sufficient stores for 10 months
Vitamin D sufficient stores for 3 – 4 months*
Vitamin K stored in small amounts Folic acid
stored in small amounts
Ferritin apoferritin in hepatocytes binds with any excess
iron to form ferritin. Iron is released from ferritin as required.
*children who live in cold climates and who remain indoors throughout the winter, may develop rickets in
the springtime, as the stores of Vitamin D acquired during preceding summer have become exhausted.

4. Detoxification / excretion of drugs and other substances

e.g. steroid hormones, insulin, parathyroid hormone

thyroxine
calcium, copper
antibiotics, such as penicillin, erythromycin, sulfonamides
When liver disease is present, feminisation of the male can occur due to accumulation of
oestradiol. This potent oestrogen is normally converted to the far less potent oestriol, when the
liver is functioning normally.

5. Extra-medullary haemopoiesis

6. Phagocytosis

Kupffer cells lining the sinusoids phagocytose senescent red cells, bacteria and
antigen:antibody complexes

91
 Digestive function of the liver

Composition(6 o0f0 Bmile – 1L produced daily)

·Bile salts − manufactured from cholesterol, from which is derived cholic & deoxycholic acids.
·Bilirubin These combine with taurine & glycine, and finally sodium → bile salts.
·Cholesterol, Fatty Acids, Lecithin
·Electrolytes, such as calcium and copper.

Functions of Bile
1. Fat digestion and absorption
2. Excretion of bilirubin, cholesterol and other substances e.g. antibiotics

1. Fat digestion and absorption

Ingested fats, mainly triglycerides, are emulsified mainly in the small intestine together with bile.
Lecithin is important in this emulsification process, and to a lesser extent, bile salts.In this process, the
fat globules are transformed into very small particles, such that their surface area is ↑ 1000-fold, and
this facilitates the action of pancreatic lipase to convert the TG → fatty acids and monoglycerides.
Bile salts now cover these molecules forming micelles, and transport them to the villi where they can be
absorbed. In the intestinal cells, chylomicrons are formed and enter lymphatic channels→thoracic
duct→blood stream.
2. Excretion

Ch olesterol
◦
1 – 2 gm cholesterol is excreted / day in the bile.
Bil irubin
◦
When the erythrocytes get old and frail after about 120 days in the circulation, they are phagocytosed by
macrophages of the reticulo-endothelial system (RES), mainly in the spleen; their contained haemoglobin
is broken down into iron and globin (recycled) and the remainder of the haem pyrrole ring is transformed
into biliverdin and then to bilirubin. Bilirubin passes out of the spleen into the circulation where it binds to
albumin, which carries it to the liver where it becomes conjugated in the hepatocytes to two molecules of
glucuronic acid to form bilirubin diglucuronide.
This is excreted in the bile, passes to the intestine where it is converted to urobilinogen by intestinal
bacteria. Of this, 20% is reabsorbed and a little (5%) appears in the urine as urobilinogen, and the
remainder is re-excreted in the bile. In the urine, urobilinogen is oxidised to urobilin, which gives the
urine its yellow colour.
The 80% urobilinogen which has not been absorbed into the portal blood, is reduced in the bowel to
stercobilinogen. When this is oxidised to stercobilin, the faeces is given its brown colour, and indole,
skatole, mercaptans and hydrogen sulphide are the malodorous products giving it its distinctive odour.

Van den Bergh Test:

Direct test is for conjugated bilirubin only

If methanol is added to the reaction, total bilirubin is measured (i.e. conjugated + unconjugated)
Indirect determination of the unconjugated form can then take place by subtraction of the two results.

92
 Jaundice

Pathway of bilirubin transport and metabolism, from spleen to biliary canaliculus

A. Bilirubin is produced from metabolism of haem, primarily in the spleen, and is transported to the
liver bound to albumin.
B.Bilirubin enters the hepatocyte by binding to a transporter protein (red crescents) and crosses the
cell membrane thus entering the cell.
C.Bilirubin is then conjugated to glucuronic acid by the enzyme glucuronyl transferase producing
bilirubin diglucuronide (Bili-(Gu)2.)
This conjugated bilirubin is then actively secreted into the canaliculi
D.
Once in the canaliculi, the conjugated bilirubin passes into the hepatic ducts and to the gall bladder
E.or down the common bile duct with the other constituents of the bile.

*Bili = Bilirubin

Bili – (Gu)2 = Bilirubin diglucuronide (conjugated bilirubin)

93
 Haemolytic anaemia

In haemolytic anaemia, unconjugated bilirubin is produced at rates that exceed the ability of the liver
to clear it, leading to an increase in unconjugated bilirubin in serum. (A)
Gilbert's disease

In Gilbert's disease, a genetically determined decrease in level of glucuronyl transferase results in

build-up of unconjugated bilirubin in hepatocytes and ultimately in serum. (C)
In Gilbert's disease, there may also be a defect in the bilirubin transporter protein (B)

Neonatal jaundice

The level of glucuronyl transferase may be reduced in the neonate → neonatal jaundice.

Viral hepatitis

In hepatitis, jaundice is produced by three mechanisms:

1. The ability of the hepatocytes to conjugate bilirubin becomes impaired ( C )

2. The active secretion of conjugated bilirubin into the canaliculi deteriorates (D)

3. Oedema may cause obstruction of the canaliculi → further cholestasis (E)

Thus these patients have ↑levels of both unconjugated and conjugated bilirubin in the blood.

Obstructive jaundice

In obstructive jaundice (which may be intra- or extra-hepatic) conjugated bilirubin is prevented from
passing freely from the hepatocyte along its normal pathway to the duodenum (E) →↑levels of
conjugated bilirubin in the blood.

There is a build-up of bile in the canaliculi, the back pressure eventually causing disruption of
hepatocyte function and inability of the cells to process bilirubin derived from senescent red cells in
the usual way (C). Eventually,↑levels of both unconjugated and conjugated bilirubin therefore occur
in the blood.
Blood: ↑Bilirubin (conjugated and unconjugated)
↑ALP, GGT
↑Cholesterol*

Urine: +ve Bilirubin (conjugated therefore soluble in plasma and urine)**

-ve Urobilinogen (bilirubin not getting through to the small intestine due to obstruction)
Faeces: ↓stercobilin***

↓Absorption of fats including fat soluble vitamins (Vitamins ADEK)

→ Steatorrhoea
Osteomalacia
Bleeding tendency (↓Factors II, VII, IX, X)
*Xanthelasma, xanthomata
**Urine dark in colour
***Stools pale, fatty, floaty and foul-smelling

94
 Metabolic Functions of the Liver

▫
Proteins
▫ Lipids
▫ Glucose
Protein Metabolism
1.Synthesis of non-essential amino acidsb y different processes, including transamination from keto-
acids

e.g. aspartate from oxaloacetate

2. Catabolism of proteins to amino acids, which may then be further catabolised and enter the citric
acid cycle with formation of urea, or be converted to glucose or fats.

Formation of urea: H2N

\
NH3 + NH3 +CO2 → C = O + H2O
/
H2N

Urea is formed from ammonia (NH3), this being a by-product of protein catabolism. In liver disease,
urea production ↓
and
ammonia builds up → hepatic encephalopathy

3. Manufacture of plasma proteins.

Albumin is manufactured at a rate of 12g/day. Albumin has a half-life of ~ 20 days, so a fall in albumin
is a relatively late sign of liver disease.
Alpha & Beta Globulins (not Gamma Globulins – these being produced by B lymphocytes)

4. Production of clotting factors:

I, II, V, VII, VIII, IX, X, XI, XII (Von Willebrand factor is produced by endothelial cells)
Factor III is tissue thromboplastin; Factor IV is calcium; Factor VI does not exist.
Factor I (fibrinogen) ↑ in liver disease, but is often structurally imperfect and mal-functional. The
production of the remainder of the clotting factors is impaired and because they have a short half-life,
coagulation tests are abnormal within a few days of onset of liver disease.

95
5. Acute phase reactants (positive):
(These are produced mainly by the liver, in response to interleukin-6) C-Reactive Protein (CRP) Amyloid P

and A
Caeruloplasmin Haptoglobin
Ferritin Mannose-binding protein
Alpha-1 Antitrypsin Complement
Fibrinogen Plasminogen activator inhibitor
Prothrombin Lipoprotein (a)
Factor VIII Hepcidin
*von Willebrand factor
*Platelets

* von Willebrand factor produced by endothelial cells

* Platelets produced in bone marrow
* thrombogenic
CRP is commonly measured as it parallels the severity of inflammation / infection / tissue injury, and
may be used as a marker for recovery / response to Rx

Acute phase reactants (negative):

Albumin
Transferrin

Typical plasma acute-phase protein changes after a moderate inflammatory stimulus. Several patterns of
response are seen: major acute-phase protein, increase 100-fold (e.g., C-reactive protein and serum
amyloid A); moderate acute-phase protein, increase 2-fold to 4-fold (e.g., fibrinogen, haptoglobin); minor
acute-phase protein, increase 50% to 100% (e.g., complement C3); and negative acute-phase protein,
decrease (e.g., albumin, transferrin)

96
6. Enzymes produced in the liver

*Alanine aminotransferase ALT

*Aspartate aminotransferase AST
*Alkaline phosphatase ALP / Alk. Phos.
*Gamma glutamyl transferase GGT / Gamma GT
Lactate dehydrogenase LDH
Creatine kinase CK
Alpha-1 anti-trypsin AAT
* Used routinely as part of the assessment of liver function

Location of hepatocellular enzymes

Alanine aminotransferase (ALT) and the cytoplasmic isoenzyme of aspartate aminotransferase (ASTc) are
found primarily in the cytosol. With membrane injury as in viral or chemically-induced hepatitis, these
enzymes are released and enter the sinusoids, raising plasma AST and ALT activities. Mitochondrial
aspartate aminotransferase (ASTm) is released primarily with mitochondrial injury, as caused by ethanol
as in alcoholic hepatitis. Alkaline phosphatase (ALP) and gamma-glutamyltransferase (GGT) are found
primarily on the canalicular surface of the hepatocyte. Bile acids accumulate in cholestasis and dissolve
membrane fragments, releasing bound enzymes into plasma. GGT is also found in the microsomes,
represented as rings in the figure; microsomal enzyme-inducing drugs, like phenobarbital and dilantin, can
also increase GGT synthesis and raise plasma GGT activity.

97
TRANSAMINASES (syn: Transferases)

ALT Alanine Aminotransferase

AST Aspartate Aminotransferase
Two isoforms of AST: ASTc (cytosolic AST)
ASTm (mitochondrial AST)

Half-lives oftransferases ALT 47 hours

ASTc 17 hours
ASTm 87 hours

Location & specificity of transferases

ALT
ALTis found in the cytoplasm of the hepatocytes, where it is present in much lower amounts than is
ASTc.
Initially, when the hepatocyte is damaged and the transaminases are liberated into the bloodstream, the
ASTc level in the blood is much higher than is the ALT level, but because of the shorter half-life of AST,
the level falls faster than does ALT. Thus, if the blood levels of these two enzymes are measured some
time after the hepatocyte injury, the ratio of AST:ALT will be found to be < 1.

ALT is sensitive to liver cell injury & is more specific for liver disease than is AST, which is ubiquitous in
the cells of the body, although present in greatest amounts in hepatocytes.
The only other organ in which ALT is found is the kidney. Its level in the blood rarely rises in conditions
affecting the kidney.
AST
AST is present in the cytoplasm of the hepatocyte (ASTc) as well as in the hepatic mitochondria (ASTm)
Found in: Increased in: Decreased in:

Liver liver disease → hepatocyte damage

Heart MI
Brain NS disease e.g. CVA
Skeletal muscle muscle injury
Kidney Chronic renal failure
Elevation in the AST:ALT ratio

If ratio of AST:ALT changes to >2 with a concomitant ↑GGT, this is suggestive of alcohol-induced liver
disease; a ratio >3 is highly suggestive.
The elevation in the ratio is caused by:

· Alcohol-induced mitochondrial damage → release of ASTm (in addition to the release of cytosolic AST
and ALT)
· Vitamin B6 (pyridoxine) deficiency in alcoholism → ↓levels of ALT & AST
Both ALT and AST depend on Vitamin B6 for their activity, ALT being more dependent than AST in
this regard.

98
Function of transferases

The aminotransferase enzymes transfer (reversibly) an amino group from an amino radical donor, such as
glutamine, to a ketoacid to form an amino acid
e.g. amino group transferred to pyruvate, to form alanine
amino group transferred to oxaloacetate to form aspartate.

Transamination of pyruvate to form alanine

Transamination of oxaloacetate to form aspartate

COOH
CH3 │
│ CH3
HCNH2* │
│ HCNH2*
COO− │
Alanine COO−
Aspartate
ALT→↕ COOH AST↕
→

C H3 │
CH3
C=O │
│
C=O
COO− │ │
Pyruvate COO−
Oxaloacetate
*amino group

99
ALKALINE PHOSPHATASE (ALP)

A group of isoenzymes which hydrolyse phosphate ester bonds in an alkaline medium, (ideally PH
9.0) generating an organic radical + inorganic phosphate
Found in: Increased in:
Liver •Hepatocellular damage
•Cholestasis
•Metastatic disease of the liver
•Passive congestion
Levels: ++++ in metastatic liver disease (prod by tumour & →
obstruction)
+++ in cholestasis
++ in hepatitis
Bone
ALP inactivates pyrophosphate, which is an inhibitor of mineralisation of osteoid.
The level of ALP ↑ in any cause of ↑ bone turnover, such as:
•Paget’s disease of bone
•Metastatic bone disease
•Physiologically at the extremes of life;

Children especially < 2 yrs

Teenagers at times of rapid growth
The elderly commonly 1.5x normal level
•Osteomalacia & rickets
•Hyperparathyroidism
•In pregnancy may reach 2 – 4 x normal by term
Placenta and
Lactating breast
•Aaftlel
W or fa s hmigahl lf iantt mesetainl e(d igestion of ingested phospholipids)

e.ugm.:
T o•Curas Lung

•Hypernephroma
▫Hodgkin disease
If Gamma GT is not ↑ along with the ALP, the ALP may be originating from a site other than the liver,
e.g. bone. ALP resides near the biliary canaliculi, in the hepatocyte cell membrane.

100
GAMMA GLUTAMYL TRANSFERASE (Gamma GT, GGT)

▫ Transfers a gamma glutamyl group from glutathione to amino acids, which enables them to be
transported across cell membranes.
• GGT is involved in the regeneration of active glutathione (gamma glutamyl-cysteinyl-glycine), thus
maintaining adequate levels of this important antioxidant.
The enzyme is found in the epithelial cells of the bile ducts and inside the microsomes of hepatocytes.

Found in: Increased in:

Liver •liver disease, esp cholestasis

•↑enzyme synthesis induced by:
◦alcohol excess*
◦drugs
e.g. anti-TB
anti-epileptic
paracetamol
*↑GGT in 60 – 70% alcoholics; level may remain ↑ for up to 1/12 after onset of abstinence

Pancreas

Kidney

GGT level in blood does not ↑ in these pancreatic and renal conditions, but ↑ levels may be present
▫ in the pancreatic secretions
▫ in the urine (GGT resides in the brush border of tubular cells)
e.g. Nephrotoxic drugs such as Cisplatin

*****
Functions of Glutathione
1. Antioxidant

Glutathione is found in many cells throughout the body and plays an important role in converting toxic
hydrogen peroxide to water.
GGT
GSH = active glutathione ↓
GS = inactive glutathione GSH → GS + H+ → GS → GSH
↓
H2O2 + 2H+ → 2H2O
2. Metabolism and Excretion of drugs
Glutathione forms complexes with certain drugs, enabling them to be excreted
e.g. paracetamol, phenytoin, carbemazepine

3. Amino acid transport across cell membranes

101
 Elevated Liver Enzymes

↑Transaminases (ALT usually >AST)

Caused by damage to hepatocytes. These enzymes are present in the cytoplasm of the hepatocytes and
are therefore readily released into the circulation when the integrity of the cell is disrupted.
Causes of hepatocyte damage

• Viral infections
• Toxic substances
• Hypoxia
• Non-alcoholic fatty liver (NAFL)
Viral infections
◦ Hepatitis A, B, C, D, E
◦ Epstein-Barr virus (EBV)
◦ Cytomegalovirus (CMV)
◦ Herpes Simplex virus
Toxic substances
◦ Alcohol
◦ Drugs e.g. Paracetamol, NSAIDS, statins, chemotherapy drugs, Amiodarone
◦ Copper Wilson’s disease
Hypoxia
Any cause of ↓perfusion of the liver→ hypoxic damage to the hepatocytes such as:
◦ Acute LV failure e.g. Acute MI
◦ Septic shock endo- and exotoxins and cytokines → hypotension
Non-alcoholic fatty liver (NAFL)
Accumulation of triglycerides inside hepatocytes in the obese patient; the enzyme elevation is reversible
with weight loss

↑Transaminases (AST > ALT)

◦ Alcohol damages mitochondria where mitochondrial AST resides (ASTm) as well as damaging the
hepatocyte membrane causing leakage of cytosolic AST (ASTc) into the circulation. Hence
disproportionate ↑AST compared to ALT, which is only found in the cytoplasm.
◦ Fulminant hepatic failure (viral hepatitis)
◦ Reye’s syndrome (severe illness with liver failure and depressed level of consciousness in children with
a viral infection, often occurring after aspirin use)

102
↑ Alkaline Phosphatase and Gamma GT (simultaneous elevation of both enzymes)

Extra-hepatic
/
Caused by biliary tract obstruction
\
Intra-hepatic

Extra-hepatic Obstruction

Common Causes
▫ Gallstones
▫ Carcinoma head of pancreas
Less Common Causes
▫ Pancreatitis/pancreatic pseudocyst
▫ Stricture of common bile duct

Intra-hepatic Obstruction

Causes
▫ Hepatitis
▫ Drugs
▫ Primary biliary cirrhosis
▫ Liver metastases

In viral hepatitis, oedema due to inflammation results in obstruction of tiny intra-hepatic biliary
canaliculi; there is also a failure of secretion of bile into the canaliculi by the hepatocytes, as the cell is
metabolising too poorly to perform this energy requiring function.
The bile accumulates in the cell and the bile salts start to digest the cell membrane wherein these enzymes
are situated (at site of exit of canaliculi from the cell), thus releasing the alkaline phosphatase and gamma
GT enzymes into the cytoplasm and then into the circulation, as the integrity of the whole cell is disturbed.
>45 Drugs have been implicated in cholestatic jaundice – the agent causes acute hepatitis which is
followed by chronic damage to the intra-hepatic biliary system.
Some examples:
Flucloxacillin, Erythromycin, Tetracycline, Chlorpromazine, Ibuprofen, oestrogens, Captopril (ACE
inhibitor), anabolic steroids

Primary biliary cirrhosis – possibly an autoimmune condition affecting middle-aged females →

inflammation commences in portal tracts and spreads to lobules, eventually → fibrosis and distortion of
architecture (cirrhosis); biliary canaliculi become non-patent.

Liver metastases as they enlarge → compression of biliary canaliculi with obstruction

↑Gamma GT (disproportionate ↑GGT compared to the other liver enzyme levels)

Caused by enzyme induction by alcohol or drugs, such as Isoniazid, Phenytoin – these agents stimulate
hepatocytes to produce Gamma GT (important in metabolism of glutathione, which is required to
metabolise the substance)

103
LACTATE DEHYDROGENASE (LDH)

Present in: Increased in:

Blood cells Haemolysis, haematological malignancies

Heart Myocardial damage eg MI
Lung Pulmonary embolism
Brain Seizures, cerebral damage, CVA
Skeletal muscle Trauma involving skeletal muscle
Kidney Renal disease
Liver Hepatitis, 1° or 2° hepatic malignancy*
Pancreas Pancreatitis
Placenta Hypotension / shock
Malignancies other than haematological e.g. metastatic melanoma
*LDH produced by tumour &/or released from hepatocytes

COO─ LDH COO─

↓ ││
H-C-OH C=O ↔
││
CH3 CH3
Pyruvate Lactate

Cori cycle
Lactic acid accumulates from glucose metabolism in working muscle, travels to the liver, where it
is converted back to glucose, which then can replenish the glucose level in the myocytes.

Liver → Muscle

Glucose Glucose
↑ ↓
Pyruvate Pyruvate
↑ ↓
Lactic acid ← Lactic acid

104
CREATINE KINASE (CK) Three isoenzymes: CK-MM, CK-BB, CK-MB

Found in: Increased in:

Skeletal muscle CK-MM (98%) & CK-MB (2%) myositis, muscle damage

Myocardium CK-MM (70%) & CK-MB (30%) MI

Brain, lung & other tissues CK-BB CVA, PE, hypothyroidism, DM

Creatine is formed in the liver from the amino acids, arginine, glycine and methionine; it is then
transported to skeletal muscle, where CK catalyses its conversion → Creatine-PO4, which serves as an
energy store for the muscle. CK also catalyses the reverse reaction, whereby ATP is released.

NH2
│
C= NH2
│
NCH3
│
CH2 CK
│↓
COO─
Creatine ↔ Creatine–phosphate
↓
Creatinine

105
 Causes of Hepatic Cirrhosis

Most common causes

Alcoholism
60 – 70%
Chronic viral hepatitis (B & C) 10%

Less common causes

NASH (non-alcoholic steato-hepatitis)

Haemochromatosis
Chronic obstructive jaundice Right-
sided heart failure
Drug-induced e.g. Methyldopa
Syphilis
Wilson’s disease
Alpha-1 antitrypsin deficiency
Cystic fibrosis
Cryptogenic

Chronic viral hepatitis

Chronic hepatitis C most common in western world, chronic hepatitis B more common in Asia & Africa

Chronic obstructive jaundice

Primary biliary cirrhosis Middle-aged ♀, cause unknown, AMA +ve in 90%

Primary sclerosing cholangitis Associated in many patients with ulcerative colitis; cause unknown,
P-ANCA +ve in 65%
Secondary biliary cirrhosis e.g. bile duct stricture

Cryptogenic

Cause cannot be identified. (biopsy in established, endstage cirrhosis non-diagnostic)

106
 Hepatic syndromes in the critically ill patient

Two hepatic syndromes occur in the critically ill patient:

1. Ischaemic hepatitis secondary to hypoxia
2. Intra-hepatic cholestasis secondary to inflammation
1. Ischaemic hepatitis

This occurs secondary to hypoxia. The hepatocytes release massive amounts of transaminases followed by
a moderate increase in bilirubin (< 100 μmol/L). This is often accompanied by prolongation of the PT and
PTT, and lactic acidosis, due to impaired hepatic function. (↓production of clotting factors, ↓absorption of
vitamin K, ↓ conversion of lactate back to pyruvate)
These patients usually recover fully if they survive (akin to acute tubular necrosis in the kidney)

2. Intra-hepatic cholestasis

This occurs secondary to an inflammatory response to trauma or sepsis. Bile fails to be secreted into
biliary canaliculi → accumulation of bilirubin inside hepatocytes (mainly conjugated bilirubin)

Six fundamental patterns of liver function tests

Condition AST ALT ALP Albumin Bilirubin Ammonia

↑↑ ↑↑ ↑ N ↑↑ N
NHepatitis
N N/sl↑ ↓ sl↑ ↑
Cirrhosis
↑ ↑ ↑↑ N ↑↑ N
Biliary
N/↑ N/↑ ↑ N N/↑ N
obstruction
*Space-
occupying
lesion
Passive sl↑ sl↑ Ns/l↑ N Ns/l↑ N
congestion
↓
Fulminant ↑↑↑ ↑↑ ↑↑ ↑↑ ↑
liver
failure

*often ↑LDH as well

107
 Nonalcoholic Fatty Liver (NAFL)

This common condition is caused by an accumulation of lipid (mainly triglyceride) inside

hepatocytes, and is manifest by ↑level of transaminases (2 -3 x normal levels). There seems to be a
low risk of progression to cirrhosis.
Some individuals have an inflammatory infiltrate and progression to hepatocyte destruction, and
these may account for some cases of “cryptogenic cirrhosis”.
This sub-group of NAFL is known as NASH (non-alcoholic steatohepatitis).

Aetiology

◦ 97% Obesity
◦ 3 % · Type II Diabetes with its attendant dyslipidaemia
· Hyperlipidaemia due to a cause other than diabetes
· Drugs e.g. Corticosteroids, Oestrogens, Tamoxifen

Symptoms and signs

Most patients are asymptomatic. They may have hepatomegaly.

Some may experience fatigue or RUQ pain.
Those who progress to cirrhosis may develop symptoms of chronic liver disease.
Treatment

Weight loss is required in the vast majority of patients.

Acute fatty liver of pregnancy is a different entity, occurring in the latter part of pregnancy or the
puerperium. Thought to be due to an abnormality in lipid metabolism, resulting in deposition of lipid in
the maternal liver. These patients become extremely ill, with anorexia, jaundice, and DIC. They have been
found to have low levels of Anti-thrombin III.
Treatment consists of transfusion of FFP and prompt delivery of the foetus.

108
 Haemochromatosis

Haemochromatosis is a common disorder of iron storage in which an inappropriate increase in intestinal

iron absorption results in deposition of excessive amounts of iron in parenchymal cells with eventual
tissue damage and impaired function of organs.
The disease is caused by inheritance of a mutant gene, termed HFE. The condition can be recognised early
on before organ damage has occurred. (genetic testing of first degree relatives, iron studies)
Haemochromatosis implies potentially severe progressive iron overload leading to fibrosis and organ
failure. Cirrhosis of the liver, diabetes mellitus, arthritis, cardiomyopathy, and hypogonadotrophic
hypogonadism are common manifestations.

Haemochromatosis is one of the most common genetic diseases. It is most common in populations of
northern European extraction in whom approximately 1 in 10 persons are heterozygous carriers and 0.5%
are homozygotes.
Expression of the disease is modified by several factors, especially alcohol consumption and dietary iron
intake, blood loss associated with menstruation and pregnancy, and blood donation. The disease is 5 to 10
times more frequent in men than in women.

Nearly 70% of affected patients develop the first symptoms between ages 40 and 60. The disease is rarely
evident before age 20, although with family screening and periodic health examinations, asymptomatic
subjects with iron overload can be identified, including young menstruating women. The penetrance of the
mutation is variable. Thus, 30% or more of homozygous individuals do not have evidence of iron
overload.

There is an increased incidence (14%) of hepatocellular carcinoma in males with long-standing

haemochromatosis.

Laboratory Findings in Hereditary Haemochromatosis

Iron Studies
Serum iron level High normal /↑
Serum transferrin level Normal
% Saturation ↑↑
Serum ferritin level Markedly ↑

Liver Biopsy
Hepatic iron concentration Markedly ↑
Total Body Iron* Markedly ↑
50g) (≤

*Normal values
Male 3.5g
Female 2.5g

109
Suspected Liver Disease

↓blood taken for LFT

Abnormal liver function tests

↓ ↓
↑
HAe↑LpTa titic: ALCPh olestatic: ↑↑
↑AS↑T G↑G↑T
±↑ ALP/GGT ↑ ALT / AST
↓
↓
Diagnostic Evaluation
Diagnostic Evaluation

Drug and alcohol history Drug and alcohol history

1. Hepatitis screen 1.Auto-antibody screen: - AMA
2. Auto-antibody screen: - ANA - ANCA
- SMA 2.Imaging studies – CT / US / MRI / ERCP
3. EBV
4. Caeruloplasmin
5. α-1-AntiTrypsin
6. Ferritin
7. α-Fetoprotein

*ANA = Anti-nuclear antibody *AMA = Anti-mitochondrial Antibody

*SMA = Smooth muscle antibody *ANCA = Anti-neutrophil cytoplasmic Ab
*EBV = Ebstein Barr Virus
ANA, SMA +ve in autoimmune diseases such as SLE
AMA +ve in Primary Biliary Cirrhosis
ANCA +ve in Primary Sclerosing Cholangitis

110
 LIPIDS
Lipids are water insoluble organic hydrophobic molecules.
Found in cell membranes, and within cells where they form borders between various aqueous
compartments, lipoproteins and adipocytes and take part in the synthesis of many compounds, such as
vitamins and hormones.
We ingest 60 – 150gm lipids/day, mostly in the form of triglycerides (TG) - 90%;
10% as cholesterol, cholesterol esters, unesterified “free” fatty acids, phospholipids

Functions of lipids

Fatty acids
•Energy source
•Insulation
•Omega-3 fatty acids →↓VLDL blood levels by enhancing the action of lipoprotein lipase and
promoting β-oxidation of FA
•Substrate for gluconeogenesis (glycerol from triglycerides)
•Form esters with cholesterol so that HDL can take up the esterified cho;esterol
Phospholipids Made up of FA + phosphoric acid + nitrogenous base

3 Types of phospholipid: Cephalin

Lecithin
Sphingomyelin

Structure of Lecithin (phosphatidyl choline)

FA─ CH2
│
FA─ CH
│
CH2─ PO4 ─ choline

•Constituent of lipoproteins, therefore important in transport of lipids

•Donates an acyl group (FA) for the esterification of cholesterol, thus enabling it to be taken up by HDL

Cholesterol + FA → Cholesterol - FA
Free cholesterol Cholesterol Ester
•Phosphate donor in metabolic reactions
•Form part of structure of cell membranes
•Myelin sheath around nerve fibers – acts as electrical insulator
•Thromboplastin -- initiates clotting cascade
•Prostaglandin production
•Emulsification of fats in the small intestine
•Constituent of surfactant

111
Cholesterol
Cholesterol occurs in the exogenous form (ingested) and the endogenous form (manufactured by many
tissues, especially the liver, also adrenal cortex, ovary, testis and intestine). On a normal diet, our
endogenous production of cholesterol > exogenous supply. The process of endogenous production of
cholesterol begins with the combination of several molecules of Acetyl CoA, resulting in formation of
Hydroxy-methyl-glutaryl-CoA. HMG-CoA reductase catalyses the conversion to Mevalonic acid. The statin
group of drugs act here to competitively inhibit this enzyme. Ultimately, cholesterol results with its steroid
structure of 4 fused hydrocarbon rings and attached 8- carbon side chain. The steroid ring structure of
cholesterol cannot be metabolised, therefore it must be excreted by conversion to bile salts or secreted in
the bile. •Forms a part of cell membranes •Converted to bile acids (80% cholesterol is converted to bile
acid) •Production of hormones – cortisol, aldosterone, oestrogen, progesterone, testosterone •Deposited
in the stratum corneum of our skin and prevents excessive fluid loss by sweating. Severely burned
patients can lose liters of fluid due to loss of this protective layer. •Substrate for vitamin D production in
the skin.

Fat Metabolism

1. Manufacture of cholesterol 2. Esterification of cholesterol to form: 3. Manufacture of fatty acids (FA)

and triglycerides if there is an excess of amino acids and glucose 4. Catabolism of FA to CO2 (β-oxidation
of fatty acids) for energy 5. Production of ketone bodies from Acetyl-CoA 6. Gluconeogenesis from
glycerol released by breakdown of triglycerides.
Fatty Acid Synthesis When there is a state of excess glucose and protein, (when we take in more than we

require), fatty acids

are synthesized from acetyl CoA, which is the end product of metabolism of proteins, carbohydrates and
fats. Acetyl CoA is carboxylated to Malonyl CoA and these two form the building blocks for FA
synthesis. Ultimately, 3 x FA combine with glycerol → TG, which is the form in which the fat is stored.
Fatty Acid Catabolism

Conversely, when our intake in insufficient for our metabolic needs, TG are broken down in adipose cells
→ FA and glycerol, the FA traveling to tissues to supply them with energy, and FA plus glycerol traveling
to the liver. Here, glycerol enters the pathway for glucose metabolism and FA are catabolised → Acetyl
CoA.
The accumulation of acetyl CoA inhibits the enzyme responsible for formation of citrate from
oxaloacetate and promotes entrance of oxaloacetate into the pathway for gluconeogenesis.
Thus, the Acetyl CoA is prevented from entering the Citric Acid Cycle, and instead is converted →
acetoacetate (ketone body); the ketone bodies then leave the liver to provide energy to the tissues,
especially the brain, which is not able to use FA for energy, as they do not cross the Blood Brain Barrier.

112
Lipoproteins

▫ Types of lipoproteins
▫ Functions of lipoproteins
▫ Enzymes involved in lipoprotein life
cycle ▫ Lifecycle of lipoproteins
▫ Fasting Lipid Screen

Types of Lipoproteins

Relative density of lipoproteins

The density of the several classes of lipoprotein is inversely proportional to the ratio of lipid,
particularly triglyceride, to protein. As lipid is less dense than protein, the more lipid contained in the
particle increases its size and decreases its density. HDL, high-density lipoprotein; LDL, low-density
lipoprotein; IDL, intermediate density lipoprotein; VLDL, very low density lipoprotein.

VisL DsyLnthesised in the liver.

LDL is derived directly from VLDL. As TG is off-loaded from VLDL (to form IDL), and cholesterol is
then acquired from HDL, IDL then becomes LDL
TG
↑
VLDL → LDL
↑
HChDoLlesterol
is synthesised de novo in the liver (main site of production) and also in the GIT.

113
Functions of Lipoproteins
VtrLaDnLs ports TG from the liver (where they are assembled) to adipose tissue for storage.
LtrDaLnsports cholesterol to the various tissues which require it e.g. skin for Vitamin D synthesis.
HDL
▫ Provides proteins to VLDL and chylomicrons from its protein layer, so that lipoprotein lipase (LPL) may
recognise them.
▫ Exchanges fats with the VLDL remnant, thus converting it to LDL
▫ Mops up any cholesterol not required by tissues and possibly also that which is being deposited at sites
of endothelial damage.

Enzymes

bLirpeoapkrso dteoiwnn li pTGas ien s–i de chylomicrons and VLDL, liberating FFA
Hbroeramkos ndeo wsenn TsGiti vines liidpea ased i-pose tissue, liberating FFA
LCAT – Esterifies cholesterol with a FA derived from lecithin, thus enabling HDL to take up the
cholesterol.

114
Lifecycle of lipoproteins
Cholesterol and triglycerides (TG) are insoluble in water, so must be transported in plasma as
lipoproteins, the inner core of hydrophobic cholesterol and TG being surrounded by a shell of
amphiphobic phospholipid and hydrophilic protein.

The more triglyceride the lipoprotein carries, the lower its density. Chylomicrons are the least dense of
the lipoproteins.
Chylomicrons are formed in the intestinal cells from dietary sources of triglycerides, cholesterol,
phospholipids and protein. They enter the thoracic duct and thence the blood, where they interact with
HDL. Proteins are received from HDL, including apo C II, which makes the chylomicron functional, in that
lipoprotein lipase is now able to break down the triglycerides contained inside the chylomicron and
liberate FA. These enter the adipose cells where they are stored and muscle cells where they provide
energy. Any FA not immediately taken up by cells becomes bound to albumin. Glycerol travels to the
liver where it is used in TG synthesis or enters the glycolytic pathway.

The chylomicron, which by now has lost most of its TG, interacts again with HDL, giving back the
borrowed protein and the remnant travels to the liver where it is degraded into its component parts.
VLDL are formed in the liver and their function is to carry TG to the tissues. The VLDL reacts with HDL,
receiving the necessary protein to make it functional; lipoprotein lipase breaks down the TG releasing
glycerol and FA as with the chylomicrons.

The VLDL now reacts again with HDL, returning the borrowed protein and receiving cholesterol,
becoming cholesterol-rich LDL. At the same time, any remaining TG is donated to the HDL which returns
it to the liver.

The LDL are endocytosed by tissue cells and their contained cholesterol is liberated for use by the cell. If
cholesterol is not required, the LDL takes it back to the liver for excretion.
HDL is formed by the liver and intestine as a disc shaped particle consisting of apoprotein and
phospholipid. The HDL particles travel to the tissues where they soon become spherical as they avidly
collect cholesterol from tissues and from IDL. The free cholesterol is esterified with an acyl group from
the phospholipid, phosphatidylcholine, under the influence of LCAT* also known as PCAT**.
Cholesterol is transported as an ester; it cannot be incorporated into HDL unless it is esterified by LCAT.
The HDL then returns to the liver and offloads its cargo of cholesterol, which is destined for excretion in
the bile. So HDL acts like a mop, cleaning up the cholesterol before it can be deposited on the vessel
walls to form an atheromatous plaque.
In liver disease, cholesterol levels are often ↓ due to decreased de novo synthesis of cholesterol and
apoprotein, (↓lipoprotein formation) whereas in cholestasis, levels of free cholesterol ↑ due to
↓production of LCAT→↓formation of cholesterol esters from phospholipids. When this is the case, the
lipid-poor HDL are catabolised at an ↑rate → ↓ levels of HDL.
Also, when there is obstruction to bile flow → cholesterol cannot be excreted in the bile in the usual way.

* LCAT = lecithin:cholesterol acyl transferase

**PCAT = phosphatidylcholine acyl transferase
(LCAT and PCAT are synonyms, lecithin being a synonym for phosphatidylcholine)

115
Fasting Lipid Screen

The fasting state is required so that the chylomicrons will have been cleared from the circulation. (This
occurs 2 – 10 hours post-prandially). As the chylomicrons transport large amounts of lipid from the GIT
(especially TG), the lipid screen assessed in the non-fasting state is not a true reflection of the lipid content
of the other lipoproteins, particularly VLDL, which mainly carries TG.
Total cholesterol value is obtained by measuring the cholesterol which is carried mainly in HDL and LDL.
(a small amount in VLDL).
HDL-cholesterol can be measured directly, and LDL-cholesterol is then derived according to the
Friedewald formula:

LDL-Cholesterol = {(Total Cholesterol HDL-Cholesterol) TG*} ÷ 2.19

─ ─

*only valid if TG <4.5 mmol/l

Total TG value largely reflects the TG carried in VLDL. A very small amount is present in HDL.

116
 Aetiology of Hyperlipidaemia

1. Primary (Familial)
2. Secondary to: Obesity/high fat diet
Nephrotic Syndrome
Chronic Renal Failure
Alcohol excess
Chronic Cholestatic Jaundice
Hepatitis
Endocrinopathies Drugs e.g. beta blockers, thiazides, oestrogen, corticosteroids

Hypothyroidism
Hypopituitarism
◦ Diabetes
Cushing’sMellitus
syndrome
◦ ◦
◦
High risk lifestyle
Obesity/ ↑fat diet

High intake of carbohydratesand fats

e.g. Fat intake constitutes >40% of total calorie intake
Saturated fats >10% of total calorie intake.
Saturated fatty acids inhibit hepatic LDL receptors →↑circulation time of LDL; they also appear to
promote formation of cholesterol from Acetyl CoA
Cholesterol >300mg/day
Consumption of excessive amounts of carbohydrates → ↑↑Acetyl CoA which is converted to
triglycerides and transported out of the liver in VLDL.
↑Adipose tissue mass acts as an endocrine organ, releasing FFA and cytokines. FFA travel to the liver,
where they are incorporated into VLDL →↑VLDL levels. FFA & cytokines promote insulin resistance →
↓lipoprotein lipase function →↑circulation time of VLDL. and ↓HDL synthesis.
Nephrotic Syndrome

Hepatic lipoprotein synthesis is stimulated as a response to the low oncotic pressure of

the ECF. This → ↑VLDL and ↑LDL. In this situation, LDL are synthesized de novo in the liver.
There is also ↑hepatic synthesis of cholesterol.
↓LCAT→↑free cholesterol
↑Lp(a)
Chronic Renal Failure

↑CRP levels
Insulin resistance → ↑VLDL
↑Production of Lipoprotein a
↑Production of
homocysteine ↑Oxidised
LDL levels
Alcohol excess

Impairment of function of lipoprotein lipase thus preventing triglycerides in VLDL from being
broken down to FFA and entering adipocytes→ ↑circulation time of VLDL
↓β-Oxidation of FFA in the liver, so ↑incorporation of FFA into VLDL

117
Hepatitis

↑VLDL production

Cholestatic Jaundice

↑Free cholesterol and ↓HDL

·↓Formation of LCAT (→ cholesterol esterification inhibited and ↓uptake of
cholesterol into HDL→↑free cholesterol levels)
·↓Excretion of cholesterol in bile.
·↓HDL due to↑rate of breakdown of cholesterol-poor HDL

Diabetes Mellitus

·↓Function of lipoprotein lipase ↑circulation time of VLDL

·↑Function of hormone sensitive lipase inside adipoctyes → breakdown of TG and FFA release
into circulation
·Glycosylation of lipoproteins causes impairment of their metabolism→ ↑levels in circulation
and ↑deposition of LDL in endothelial lesions.
·↑Levels of small, dense LDL (more atherogenic than large, buoyant LDL)
·↑Oxidised LDL
·↑Lp(a) in type II (acute phase reactant)

Hypothyroidism

↑LDL, ±↑TG, ±↑ HDL

·↓Rate of catabolism of LDL
·↓Function of hepatic LDL receptors
↑ ·Homocysteine (→ oxidation of LDL and insulin resistance)
Cushings Syndrome

Cortisol → hyperglycaemia, by stimulating gluconeogenesis → chronic stimulation of islets of

Langerhans. Eventually, the production of insulin falls → diabetic state with ↑VLDL levels.
Anti-insulin effect of cortisol on adipose tissue → breakdown of TG and release of FFA into
circulation
Cortisol → truncal obesity which predisposes to development of Type II diabetes.

Lifestyle

Habitual excessive alcohol ingestion, obesity and lack of exercise are lifestyle risk
factors for hyperlipidaemia

Appropriate investigations to exclude secondary hyperlipidaemia

Fasting blood glucose Diabetes, Cushings syndrome

U&E Chronic renal failure
PCR Nephrotic syndrome
LFT Obstructive jaundice
Alcoholism
Hepatitis
TSH Hypothyroidism

118
 Obesity and Type II Diabetes
The expanded adipose tissue mass acts as an endocrine organ, secreting into the circulation:
1. Free Fatty Acids
2. Cytokines ◦ Tumour necrosis factor (TNF)
Interleukin-6 (IL-6)
◦
Resistin - a cytokine which decreases tissue sensitivity to insulin
◦3. Plasminogen activator inhibitor (PAI-1)

At the same time, there is ↓secretion of two substances normally secreted by adipose tissue, both of which
are insulin sensitising, namely
1. Adiponectin
and
2. Leptin
Free Fatty Acids (FFA)
The ↑levels of FFA arriving at the liver inhibit the formation of citrate from oxaloacetate and acetyl CoA
(citric acid cycle) , instead promoting conversion of oxaloacetate to phosphoenolpyruvate, a precursor of
glucose in the gluconeogenesis pathway.
Glucose
Gluconeogenesis ↑
Phosphoenolpyruvate
FFA +ve→ ↑
Oxaloacetate + Acetyl CoA→ Citrate
↑
FFA −ve
This results in ↑blood glucose level which stimulates insulin release from the pancreas. Insulin however, is
prevented from performing its function of promoting transport of glucose into tissue cells, due to the anti-
insulin effects of FFA and cytokines (and the loss of the insulin-sensitising effect of adiponectin and
leptin) Net result is ↑blood levels of glucose and insulin.
Fate of FFA arriving at the liver:

Excessive amounts of FFA arriving at the liver result in ↑ production of VLDL. These enter the circulation
but due to the anti-insulin effects and loss of insulin-sensitising effects mentioned above, the VLDL are
not able to offload their cargo of TG due to the ↓activity of the enzyme, lipoprotein lipase. Net result is ↑
levels of VLDL which remain in the circulation for longer.
Enhanced function of the enzyme, hormone sensitive lipase inside adipose tissue cells, results in
↑breakdown of TG inside fat cells, with pouring out of FFA into the circulation.

Increased blood glucose levels:

Blood glucose levels increase due to promotion of gluconeogenesis and to impaired insulin function. LDL
become glycosylated → impairment of their metabolism, longer circulation time and ↑ deposition in areas
of endothelial damage. The cytokines, IL-6 and TNF stimulate production of acute phase proteins in the
liver, including CRP, fibrinogen, prothrombin and Lp(a). They also stimulate release of plasminogen
activator inhibitor (PAI) from adipose tissue. A prothrombotic and proinflammatory state is created which
in the milieu of the lipid abnormalities (↑VLDL, ↑glycosylated LDL, ↑small dense LDL, ↑ oxidised LDL,
↑Lp(a), ↓HDL) predisposes to intimal damage and plaque formation.

119
Hypertension in Type II Diabetes
Insulin
promotes development of hypertension by:
Enhancing sodium reabsorption in the kidneys
◦
Stimulating the sympathetic nervous system
◦
Cytokines and FFA may also contribute to production of hypertension.

Development of type 2 diabetes. Insulin resistance associated with obesity is induced by adipokines,
(cytokines released from adipose tissue) free fatty acids, and chronic inflammation in adipose tissue.
Pancreatic β cells compensate for insulin resistance by hypersecretion of insulin. However, at some point,
β-cell compensation is followed by β-cell failure, and diabetes ensues.

120
 Glucose Metabolism

The liver has the important role of maintaining a steady blood glucose level, so that tissues which are
dependent on glucose as an energy source, such as the brain and red blood cells, have a constant supply.
When glucose is plentiful, it is converted to glycogen and stored in the hepatocytes. When the capacity is
reached for storing glycogen, any surplus glucose is converted to triglyceride (TG) (aka triacylglycerol)
Triglyceride consists of: 1 x Glycerol
3 x Fatty acids (FA)
Glycerol is derived from Glyceraldehyde -3- P (from the glycolytic pathway)

FA are derived from Acetyl-CoA, which in turn is derived from pyruvate, one of the end-products of the
glycolytic pathway. CoA is supplied by the vitamin, Pantothenic Acid.
Pyruvate
↓ ← CoA -Pantothenic Acid
Acetyl CoA

Acetyl CoA is the first step along the path towards fatty acid synthesis. (Acetyl CoA combines with
Malonyl CoA and then variable lengths of Acetyl CoA chains are added to this to form the various fatty
acids.
Thus, all components of triglycerides can be derived from products of glycolysis.
When the glucose level in the blood is too low, glycogenolysis takes place and then, if required,
gluconeogenesis, that is, the formation of glucose from amino acids and TG.
Glucose from fats: TG are broken down to FA + Glycerol; the Glycerol is converted to Glyceraldehyde
-3-P, which can then, in the reverse direction of the glycolytic pathway, be converted to glucose.
Glucose from amino acids: Amino acids are converted back to their α-keto acid equivalents and then
directly or via the citric acid cycle, are metabolised to oxaloacetate, thence to phospho-enol-pyruvate and
then upwards (reverse glycolysis) to form glucose. All the amino acids except leucine and lysine are
capable of forming glucose in this way.

121
 Investigations in Diabetes Mellitus (DM)

Investigations which aid in diagnosis of suspected DM

1.Urine dipstix for glucose and ketones, and protein

2. Fasting blood glucose ≥ 7 mmol/L

3. Random blood glucose > 11 mmol/L

If results equivocal, oral Glucose Tolerance Test may be required.

Investigations which aid in classification of the type of DM

Serum insulin or C-peptide levels

◦
C-peptide (connecting peptide) forms part of the pro-insulin molecule, and can thus be used as a direct
measure of the patient’s insulin level in a 1:1 ratio. (It is technically easier to measure than insulin is)
Measurements do not always distinguish type 1 from type 2 DM, but a low C-peptide level
characteristically occurs in Type I diabetes, while in Type II there may be a normal or ↑level.
Islet cell antibodies measured at the time of diabetes onset may be useful if the type of DM is not clear.
◦

Investigations to assess possible complications of DM

Urea, creatinine, electrolytes to assess renal function and electrolyte status -hyponatraemia and
◦
hyperkalaemia characteristic of DKA
Fasting lipid screen - ↑triglycerides characteristic in poorly controlled type II diabetes
◦
◦ Baseline and Stress ECG - ↑risk IHD
Arterial Blood Gas Analysis – high anion gap acidosis in DKA
◦

In suspected Hyperglycaemia, Hyperosmolar Syndrome - HHS aka HONK:

· p-Osmolality – markedly ↑due to profound dehydration, ↑urea and ↑↑glucose

(Very mild / no acidosis; ketones usually negative in urine)

122
 The Metabolic Syndrome

The NCEP (National Cholesterol Education Program) Adult Treatment Panel III defined
metabolic syndrome as the occurrence of ≥ three of the following criteria:

Hypertriglyceridaemia (fasting triglyceride level ≥1.7mmol/L)

▫

Low HDL levels

▫

Insulin resistance (fasting glucose ≥6.1mmol/L)

▫

Truncal obesity (waist circumference:>102cm in men, >88cm in women)

▫

Hypertension (BP ≥130/85mmHg or documented use of antihypertensive therapy)

▫

Patients often have ↑ levels of lipid-depleted LDL (sometimes referred to as "small, dense LDL")

and substantially increased CHD risk.

The metabolic syndrome affects 25% of adults and is common in CHD patients; hence, identification of
moderate hypertriglyceridaemia in a patient, even if the total cholesterol level is normal, should trigger an
evaluation to identify this disorder

Metabolic syndrome is not a disease, but a cluster of metabolic disturbances

Insulin resistance (and perhaps also hyperinsulinaemia) is considered to be a key pathogenetic factor in
the development of other features of metabolic syndrome, such as abnormal glucose tolerance,
hyperlipidaemia and hypertension. Central obesity promotes insulin resistance, although insulin
resistance has a strong genetic component and not all insulin-resistant individuals are overweight

123
 Disturbances of blood glucose levels

Hyperglycaemia
Hyperglycaemia occurs in two main settings:
1. Patients without previously documented Diabetes Mellitus (DM)

New onset DM (Type I or type II)

◦
Gestational diabetes
◦
Acute stress
◦
Trauma, surgery
Acute MI, CVA
Severe illness, including infection
Endocrine disorders
◦
Steroid administration
Cushings disease
Acromegaly
Drugs
◦
Thiazides
Beta blockers
Phenytoin
Opiates
Pancreatic injury
◦
Pancreatitis (acute or chronic)
Haemochromatosis (“Bronze diabetes”)
Factitious
◦
Taking blood from a vein into which is being infused a dextrose containing
solution

2. Patients with documented Diabetes Mellitus (DM)

The underlying precipitants of elevated blood glucose in these patients include:

Acute stress
◦
Intercurrent illness
Surgery, trauma

Drugs
◦
e.g.Thiazides

Non-compliance with diet or hypoglycaemic medication

◦

124
Hypoglycaemia

Drugs
◦
Insulin
Sulphonylureas
Alcohol
Critical illness
◦
Hepatic failure
Renal failure
Overwhelming sepsis with organ failure
Starvation

Hormonal deficiencies
◦
Cortisol
Growth hormone
Epinephrine
Insulinoma
◦
Other
◦
Post-prandial hypoglycaemia

125
Haematology – learning objectives

Essential

Pre reading
9 Understand the components of a FBC: red cells ( Hb, MCV, PCV/Haematocrit, reticulocytes),
platelets; white cells (total count and differential – lymphocytes + granulocytes (monocytes,
neutrophils, eosinophils, basophils) reading pp
9 Normal development of white and red cells (marrow production of immature forms, maturation in
marrow to mature forms, which are then released into circulation etc)
9 Coagulation pathways (extrinsic and intrinsic)

In course
9 Understand the common causes of polycythaemia (primary + secondary: smoking)
9 Understand the 5 common anaemias:
¾Iron deficiency using chronic blood loss as an example
¾Megaloblastic anaemia using the examples of pernicious anaemia and dietary folate deficiency
¾Chronic disease using the example of rheumatoid arthritis
¾Haemolytic anaemia using sickle cell disease as a clinical example
¾ Acute blood loss using post-operative haemorrhage as an example
9 Understand and accurately interpret iron studies using clinical examples of iron deficiency
anaemia, anaemia of chronic disease and haemochromatosis
9 Understand the common causes of leukopaenia (viral infections e.g. EBV)
9 Understand the common causes of leukocytosis (bacterial infections e.g. Strep infections)
9 Understand the common causes of thrombocytopaenia (ITP)
9 Understand the common causes of thrombocytosis (acute phase reaction)
9 Understand the clinical use of INR and PTT (anticoagulation therapy)
9 Understand the role of the acute phase reactants - fibrinogen, prothrombin, factor VIII and
platelets - in the development of DVT

Important

¾Understand the difference between round and oval macrocytes in macrocytic anaemia
¾ Understand the clinical relevance of Factor V Leiden (homozygous)

Desirable
9 Understand the less common causes of polycythaemia: high altitude, cyanotic congenital heart
conditions
9 Understand the clinical effects of untreated/undiagnosed haemochromatosis on liver function,
cardiac muscle, joints and pituitary gland.
9 Understand the types of anaemias seen in patients with autoimmune conditions
9 List the common conditions where anticoagulation therapy is indicated

126
Haemopoiesis

127
128
 RED CELLS

Normal structure of the red cell membrane

Molecular binding interactions among the major proteins of the red cell membrane

ANK = ankyrin; GP = glycophorin.

The lipids of the red cell membrane consist mainly of phospholipid and cholesterol, with interspersed
glycophorin and other proteins.
The deeper cytoskeleton, which is attached to the under surface of the membrane, is made up mainly
of the proteins spectrin and actin.

Spherocytes and Poikilocytes

The structure of and interplay between these layers confers on the red cell its unique ability to deform,
as it traverses the heart, blood vessels and spleen. The ratio between the amount of cell membrane
(surface area) and contents of the red cell (volume) is critical; when the ratio is decreased,
spherocytosis results, when the ratio is increased, stomatocytosis or target cells result.
Hereditary spherocytosis (HS) is a relatively common abnormality of red cells in individuals of
northern European descent, with an incidence of 1/5000. It is usually transmitted as a dominant
condition, but some cases (25%) are recessively inherited. The defect lies in the cytoskeleton,
affecting either spectrin or ankyrin. The affected red cells have reduced deformability and lose
membrane when they traverse the narrow passages in the splenic cords, and also when exposed to the
high pressures and shearing forces as they travel through the circulation. When first formed in the
marrow, HS red cells are morphologically normal, but as they lose progressively more membrane on
their travels, they become spherical in shape.
Normal red cells become more fragile as they age. The membrane proteins denature as the cells age,
and auto antibodies collect on the cell surfaces. This results in decreased deformability which causes
them to haemolyse more readily than normal during their passage through the spleen. The splenic
macrophages also damage the surface of the cells, as they phagocytose the Ag:Ab complexes situated
thereon, and this also makes the cells more than usually fragile.

129
130
 CLASSIFICATION OF ANAEMIA

Anaemias may be classified depemndeicnhga onni stmhe of their production or according to the mean
cellvolume of the red cells.
Mechanism
Examples
1.ĻProduction (bone marrow failure)

ƓBone marrow aplasia/hypoplasia

Aplastic anaemia
(empty marrow)
Uraemia
Hypothyroidism

ƓBone marrow infiltration Myelofibrosis 1º (myeloproliferative)

(packed marrow) Myelofibrosis 2 º to: metastases
leukaemia esp. CML
lymphoma
myeloma
2. DƓe fNeocrtmivael RsBteCm ( bcoenllse, mhaaermroawt ifnuicn cdteiofinciienngc byu: t producing abnormal red cel
Iron deficiency
Iron unavailable – anaemia of chronic disease
ƓAbnormal stem cells Vitamin B12/folate deficiency- megaloblastic anaemia
Myelodysplasia
•Acquired Hereditary spherocytosis
•Hereditary
Ļ
3Ɠ.LBifloeosdp alons osf RBC (marrow functioning and producing normal red cells)
ƓHaemolysis
Acquired red cell defects
e.g. from prosthetic heart valve

Classification of anaemia based on MCV

Volume of Red Blood Cells 1. Condition

Normocytic Chronic disease (75% are normocytic)

M CV 80 – 100 fl Chronic renal failure
Haemorrhage
Haemolysis
BM hypoplasia
BM infiltration
2. Microcytic Iron deficiency
MCV < 80 fl Chronic disease (25% become microcytic as the chronic disease progresses)
Thalassaemia
Sideroblastic anaemia (uncommon)
Hyperthyroidism (uncommon)

3. Macrocytic Megaloblastic (oval macrocytes)

MCV > 100 fl Myelodysplasia
Liver disease
Hypothyroidism
Haemolysis (ĹĹreticulocytes)

* Alcohol is a very common cause of macrocytosis, with or without anaemia.

131
RED CELL INDICES

Units Ref Range

Hb (Haemoglobin) g/L (F 115 – 160)

(M 120 – 180)
RCC (Red cell count) x 10¹²/L (F 3.8 – 5.2)
(M 3.5 – 6.0)
Hct /PCV (Haematocrit / Packed Cell Volume (F 0.33 – 0.47)

= the proportion of blood occupied by erythrocytes) (M 0.35 – 0.51)

MCV (Mean Corpuscular Volume = volume of red cells) femtolitres (fL) (80 – 100)

*MCH (Mean Corpuscular Haemoglobin)

*MCHC (Mean Corpuscular Haemoglobin Concentration)

*Not routinely measured

Please note: MCHC may be useful in microcytic anaemias

ĹMCHC in Hereditary Spherocytosis (small dark cells)

Ļ MCHC in Iron deficiency / Thalassaemia
(small pale cells)

132
Some Common Anaemias

1. Iron deficiency (IDA)

2. Anaemia of chronic disease

3. Megaloblastic anaemia

4. Anaemia caused by haemorrhage

5. Anaemia of renal failure

6. Haemolytic anaemia

133
 Iron Deficiency Anaemia

Iron deficiency anaemia is the most common type of anaemia worldwide; 30% of the world’s population is
anaemic, and half of these have iron deficiency.

Causes

ƒ Blood loss
In adults, the cause is usually chronic blood loss, and a source of bleeding must be established. In
premenopausal Ƃ, the cause is often Ĺ menstrual loss. In other individuals, chronic blood loss from the GIT
must be excluded, such as: Ca bowel, PUD, gastritis, NSAID/aspirin use, hookworm, angiodysplasia,
inflammatory bowel disease, diverticulitis, polyps.
ƒ Rapid growth
Stores may be inadequate during periods of Ĺgrowth, such as the Ĺgrowth rate in the teenage years, and in
pregnancy (growing foetus)/infancy, exacerbated by prematurity and breast feeding.
ƒ Dietary deficiency.
The diet may be deficient in iron. Good sources are meat, fish, cabbage, broccoli, peas, beans, iron-
enriched cereals and bread.
ƒ Malabsorption of iron from GIT
Iron may be ingested but inadequately absorbed from the GIT, a common cause being coeliac disease in
children.
ƒ Haemosiderinuria
An unusual cause of iron deficiency is loss of iron in the urine due to haemosiderinuria, from chronic
intravascular haemolysis
Symptoms Signs

Tiredness Koilonychia
Pica Cheilosis, including angular stomatitis
Pagophagia
Dysphagia (Plummer-Vinson syndrome)

Investigations

•FBC
A microcytic anaemia is characteristic. ĻHb ĻMCV ĻMCH
Hypochromic red cells ĻMCHC ĹRDW
Anisocytosis (variation in size). Pencil poikilocytes
Pencil and cigar poikilocytes are characteristically seen. ĹPlatelets
A thrombocytosis is often present.

• Iron studies

Serum Iron Ļ ȝmol/L 10 - 30

Transferrin Ĺ g/L 1.6 – 3.0
Transferrin IBC Ĺ ȝmol/L 40 - 75
Transferrin Saturation Ļ % 15 - 45
Serum Ferritin Ļ ȝg/L 10 – 200

134
 Iron deficiency anaemia, post-transfusion. The cells are pale with an enlarged central pallor, in sharp
contrast to the transfused normochromic cells. In this patient, many of the cells are not particularly
microcytic, and a combined deficiency of iron, vitamin B12 or folate may be present.
This smear is an example of a dimorphic picture (two populations of cells)

The iron cycle

Iron metabolism can be thought of as a closed loop involving circulating diferric transferrin (each molecule of
transferrin carries 2x molecules of iron), the erythroid bone marrow, circulating erythrocytes, and
reticuloendothelial macrophages. Most iron in the body can be found in this cycle.
A small amount is absorbed and lost through the intestinal mucosa.

Additionally, iron in excess of tissue needs is stored in the liver. For simplicity, other sites of iron use are not
shown here. The most important of these is muscle, where iron is incorporated into myoglobin.

135
 Anaemia of Chronic Disease

The anaemia of chronic disease occurs in inflammatory conditions, infection, tissue injury and malignancy,
all of which have Ĺlevels of inflammatory cytokines and of the acute phase protein, hepcidin. The anaemia
develops in part due to inadequate iron delivery to the marrow, in spite of normal or increased iron stores.
The ferritin level is often increased 3x over basal levels, and is the most distinguishing feature
differentiating this type of anaemia from true iron deficiency anaemia.

Cytokines
Ɠ inhibit release of erythropoietin (EPO) from the kidney
Ɠ suppress the response of the marrow to EPO
Ɠ promote haemolysis of senescent red cells
Ɠ promote release of hepcidin from the liver (acute phase response)

Ļ red cell production in marrow

/
Cytokines ņ Ļ red cell survival
\
Ĺ hepcidin

Hepcidin
Inhibits iron absorption from the intestine and inhibits iron transfer from marrow particles to developing
erythrocytes and release of iron from other storage sites. These effects cause a fall in serum iron and poor
haemoglobinisation of red cells.
Ļ iron absorption
/
Hepcidin
\
Ļ release of iron from stores

136
 Anaemia of renal failure

Anaemia of renal failure is caused by:

Ɠ ĻErythropoietin production by the failing kidney

Ɠ Bone marrow suppression by toxic uraemic metabolites, and low levels of carnitine required for normal
haemopoiesis
Ɠ Decreased red cell lifespan (lowgrade haemolysis) – cells affected by uraemic metabolites, cytokines and
echinocytes have Ļlifespan
Ɠ Some patients who are on dialysis may develop iron deficiency occasioned by the dialysis procedure

Iron studies in Hypoproliferative Anaemias*

Tests Iron Deficiency Inflammation Renal Disease

Serum Iron Ļ Ļ Ļ Ļ Ļ Normal

Transferrin Ĺ Normal or Ĺ Normal

TIBC Ĺ 2–4+ Normal

Saturation (%) Ļ Normal

Serum ferritin ( g/L ) Ļ Normal

Iron stores 0 1–4+

Note: TIBC, total iron-binding capacity.

*Hypoproliferative anaemia = Reticulocyte count <2.5 % (low for degree of anaemia)

NORMAL VALUES

Iron Studies Units

Ref Range
Serum Iron ȝmol/L 10 - 30
1.6 – 3.0
Transferrin g/L
40 - 75 15
Transferrin IBC ȝmol/L
- 45 10 -
Transferrin Saturation %
200 80 –
Serum Ferritin Assay ȝg/L
100 1 - 3+
MCV fL

Marrow iron stores

137
 Megaloblastic Anaemia

Causes Ɠ Folate deficiency

Ɠ Vitamin B12 (cobalamin) deficiency
Ɠ Myelodysplastic syndrome (refractory anaemia)
Ɠ Drugs: Anti-folate drugs e.g. Methotrexate
Drugs which affect DNA synthesis e.g. Cytosine Arabinoside

The cause is usually deficiency of either Vitamin B12 or folate. The marrow is cellular, and the anaemia is
based on ineffective erythropoiesis. The common feature of all megaloblastic anaemias is a defect in DNA
synthesis that affects the rapidly dividing cells in the bone marrow.
Sources: Vitamin B12: animal products – meat, fish, dairy products
Folate: liver, yeast, spinach, other greens, mushrooms and nuts.

Clinical Features

Many asymptomatic patients are detected through the finding of a raised mean corpuscular volume (MCV)
on a routine blood count.
The main clinical features in more severe cases are those of anaemia.

Anorexia is usually marked and there may be weight loss, diarrhoea, or constipation. Glossitis, angular
cheilitis, a mild fever in the more severely anaemic patients, jaundice (unconjugated), and reversible
melanin skin hyperpigmentation may also occur with deficiency of either folate or cobalamin.

Thrombocytopaenia and leukopaenia may occur. Patients are predisposed to infections, particularly of the
respiratory or urinary tracts, and prone to bruising or bleeding.
Infertility is common in both men and women

Haematologic Findings

Oval macrocytosis, usually with anisocytosis and poikilocytosis, is the main feature. The MCV is usually
>100 fL. Some of the neutrophils are hypersegmented (more than five nuclear lobes = right shift).
Leukopaenia and thrombocytopaenia are usually not severe.

Ineffective erythropoiesis ĺ death of nucleated red cells in the marrow (intra-medullary haemolysis).

Evidence for haemolys:i s

Urine Blood

ĹUrobilinogen ĹUnconjugated bilirubin

Haemosiderinuria +ve ĻHaptoglobin level

ĹLactate dehydrogenase (LDH)

138
 Vitamin B12 Deficiency
Causes:
Ɠ Nutritional Vegans
Ɠ Autuimmune Pernicious anaemia
Ɠ Gastric causes Gastrectomy (partial/total)
Ɠ Intestinal causes Congenital deficiency of intrinsic factor
Crohn’s disease
Tropical sprue
Fistula, blind loop, stricture, ileal resection

Actions of vitamin B12

Pernicious anaemia (PA)

PA may be defined as a severe lack of IF due to gastric atrophy. It is a common disease in north Europeans
but occurs in all countries and ethnic groups. IF is required for absorption of vitamin B12 in the ileum.
The disease occurs more commonly in close relatives and in persons with other autoimmune diseases,
e.g. thyroid diseases, vitiligo, hypoparathyroidism, and Addison's disease. It is also associated with
hypogammaglobulinaemia, with premature graying or blue eyes, and in persons of blood group A
The life expectancy is normal in women once regular treatment has begun. Men have a slightly subnormal
life expectancy as a result of a higher incidence of carcinoma of the stomach

Investigations
ƕS le-Vveitla tmo icno Bnf1ir2m diagnosis, as well as s-Folate level and Iron studies, as a mixed
deficiency may be present.
ƕ Gastric Biopsy shows atrophy of all layers and an absence of parietal and chief cells

ƕ Antibodies

Intrinsic Factor (IF) antibody:

Two types of this antibody may be found in the sera of patients with PA.
· "Blocking," or type I, antibody prevents the combination of IF and vitamin B12
· "Binding," or type II, antibody prevents attachment of IF to ileal mucosa.

Parietal cell antibody

Present in the sera of almost 90% of adult patients with PA but is not specific for PA.

Treatment of Vitamin B12 deficiency ·

Vitamin B12 injections (1000 ȝg weekly for 1 month, then monthly thereafter)
· Intranasal vitamin B12 (1000 ȝg daily) for nutritional deficiency
· Oral vitamin B12

139
When treatment is commenced for a megaloblastic anaemia induced by vitamin B12 deficiency, or a mixed
deficiency of vitamin B12 and folic acid, the patient should first receive a loading dose of vitamin B12
before folic acid treatment is commenced, to prevent precipitation of subacute combined degeneration of
the cord. (In a mixed deficiency, if folate alone is given, the marrow may respond by increasing
erythropoiesis thus utilising the last remaining amount of vitamin B12, and causing SACDC)

Folate Deficiency

Causes
ƒ Dietary
ƒ Intestinal malabsorption

ƒ Excess utilisation or loss

Physiologic
Pregnancy and lactation, prematurity
Pathologic
Chronic haemolytic anaemias
Malignant diseases:
Inflammatory/infective diseases: e.g.TB

Actions of Folate

*Conversion of homocysteine to methionine, this reaction requiring vitamin B12 as cofactor

Investigations
S-Folate, (Red cell folate), S-Vitamin B12, Iron studies
Treatment
Folic acid 1 – 2mg orally daily
Peripheral blood smear in megaloblastic anaemia, showing hypersegmented neutrophils & oval macrocytes

140
 Anaemia caused by acute haemorrhage

Causes
Ɠ Trauma to a large blood vessel
Ɠ Erosion of an artery by e.g. peptic ulcer or neoplasm
Ɠ Failure of normal haemostasis
Sudden loss of ѿ blood volume may be fatal, whereas more gradual loss of Ҁ total blood volume over 24
hours may still be compatible with life.
Symptoms and signs (due to acute loss of blood volume and hypoxia):
Faintness, thirst, sweating, tachycardia, tachypnoea, postural hypotension (initial ĹBP due to
vasoconstriction may occur); subsequent sustained hypotension and death.

Laboratory findings During and immediately following acute haemorrhage, the red cell count (RCC),
Haemoglobin (Hb) and haematocrit (Hct) may be relatively normal due to vasoconstriction. Within a few
hours, tissue fluid enters the circulation ĺ haemodilution and ĻRCC, ĻHb and ĻHct. The anaemia is
normocytic. Leukocytosis and thrombocytosis may occur. Several days later, reticulocytes start to
appear in the peripheral blood. If the haemorrhage was massive, early red cells (normoblasts) and
white cells (left shift) may be seen = leukoerythroblastic blood picture, indicative of marrow response
to the blood loss.

Reticulocytes with reticular material after methylene blue staining

141
142
143
146
147
148
149
150
 Coagulation

Coagulation is initiated by tissue factor (TF) exposure, which, with factor (F)VIIa, activates FIX and FX, which in
turn, with FVIII and FV as cofactors, respectively, results in thrombin formation and subsequent conversion of
fibrinogen to fibrin. Thrombin activates FXI, FVIII, and FV, amplifying the coagulation signal. Coagulation requires
calcium (not shown) and takes place on phospholipid surfaces, usually the activated platelet membrane.
Extrinsic pathway: Initiated by activation of FVII by TF

Intrinsic pathway: Initiated by activation of FIX by FVII:TF complex or by FXIa (FXI activated by FXIIa, or by
thrombin)
Common pathway: Initiated by activation of FX ĺ FXa which, together with FVa, platelet factor 3 and FIV (calcium),
then activates prothrombin

151
152
Warfarin efficacy is tested by the Prothrombin Time (PT) and reported as the INR (International
normalised ratio). This is the ratio of the patient’s PT to a normal control PT, standardised
thromboplastin having been used in the tests.
Hise tpesatreind ebfyf itchaec yPartial Thromboplastin Time (PTT)

Normal ranges:

INR 0.9 – 1.2

PT 10 – 13 seconds PTT 26

– 41 seconds

153
Prothrombin Time (PT) tests integrity of the extrinsic (and common) pathways (factors II, V, X,
VII). The reagent used is placental or recombinant thromboplastin.
Partial Thromboplastin Time (PTT) tests integrity of the intrinsic (and common) pathways (factors
II, V, X, VIII, IX, XI, XII). Reagents used: silica, phospholipids (derived from animal tissue, & Ca++
Thrombin Time tests the efficacy of fibrin production from fibrinogen

Exogenous thrombin is added to the specimen & time taken for clot formation. It is a direct test of
fibrinogen function. Prolongation occurs if fibrinogen is mal-functional (dysfibrinogenaemia)
Ļ/

Thrombin

Fibrinogen ĺ Fibrin

Indications for anticoagulation therapy

Heparin:
• Venous thromboembolism treatment
• Unstable angina
• Acute myocardial infarction
• Coronary angioplasty
• Surgery requiring cardiopulmonary bypass
• Other high-risk patients undergoing surgery
Warfarin:
• Deep venous thrombosis (DVT) treatment/prophylaxis •
Pulmonary embolism (PE)
• Prosthetic heart valve
• Atrial fibrillation
• Ischaemic stroke
• Post acute myocardial infarction

Aspirin:
• Myocardial infarction prophylaxis
ƕ Patients at risk for a coronary event
ƕ Patients with stable coronary artery disease
• Coronary angioplasty to prevent re-stenosis and thrombosis
• In combination with warfarin
ƕ Mechanical prosthetic heart valves
ƕ Atrial fibrillation
Clopidogrel: Oral anti-platelet drug which acts by irreversibly modifying the platelet receptor for
ADP, thus preventing platelet aggregation in response to ADP.
• Atrial fibrillation
• CVA/TIA
• STEMI
• ACS
• PVD

Direct thrombin inhibitors: prevent conversion of fibrinogen to fibrin

Glycoprotein inhibitors: block binding of fibrinogen onto the glycoprotein receptor site
on the platelet

154
 Mechanisms of action of anti-platelet therapies

Direct thrombin inhibitors

Ņ

ADP = adenosine diphosphate

cAMP = cyclic adenosine monophosphate

COX = cyclooxygenase

GP = glycoprotein

TXA2 = thromboxane A2

155
 RISK FACTORS FOR THROMBOEMBOLISM

Patient

· Age > 40 years

· Obesity
· Prolonged immobility (long plane trips, paralysis) ·
Pregnancy / puerperium
· Oestrogen Rx (oral contraceptive)
· Previous DVT / PE
· FH DVT / PE
· Varicose veins
· Dehydration

Disease

· Fractures of pelvis, hip, lower limb

· Major surgery esp. abdominal / pelvic / orthopaedic involving lower limb ·
Malignancy
· Heart failure
· Myocardial infarction (mural thrombus)
· Ventricular aneurysm
· Atrial fibrillation
· Infection e.g. pneumonia
· Inflammatory bowel disease
· Nephrotic syndrome
· Homocysteinaemia
· Paraproteinaemia (B cell neoplasms causing ĹĹgamma globulin levels)
· Polycythaemia (Erythrocytosis)
· Thrombocytosis
· ATT, Protein C, Protein S deficiencies
· Lupus anticoagulant (anti-phospholipid syndrome)
· Factor V Leiden (resistance to Protein C)
· Prothrombin gene mutation

156
 Investigations for venous thromboembolism (VTE)
D-dimer

D-dimers are formed by the action of plasmin on cross-linked fibrin and imply the presence of a clot
recently formed.
Elevated D-dimer levels may occur in the following situations:

ƕ DVT

ƕ Recent trauma

ƕ Bleeding

ƕ Hospitalisation

ƕ Advanced age

ƕ Malignancy.

This test is therefore not specific for deep vein thrombosis, but the diagnosis should not be considered
if a negative result is obtained.

Doppler Ultrasound

This test is more reliable when deep vein thrombi are more proximally situated.

Pulmonary artery CT scan

This scan is helpful in locating an embolus in a major pulmonary artery, but may not detect more
distally situated emboli
ECG

Sinus Tachycardia (one of the most common ECG findings in this situation)

T wave inversion V1 – V4 due to right ventricular strain (the commonest ECG abnormality in PE)

Ventricular ectopic beats

Atrial fibrillation

Right bundle branch block

SIQ3T3

S1 (Deep S wave in Standard Lead I) signifies development of acute right axis deviation due to
sudden increase in right sided pressure and right ventricular dilatation.
Deep Q waves and T wave inversion develop in Standard Lead III - ? rationale for this

Echocardiography

Not performed routinely, but may show right ventricular hypokinesis, persistent pulmonary artery
hypertension and free floating clot in right ventricle

157
 Disseminated Intravascular Coagulation (DIC)

Widespread thrombus formation in small capillaries caused by:

1. Release of a substance into the circulation which initiates clotting

2. Widespread damage to endothelial cells ĺ initiation of clotting

Thrombi (consisting of platelet aggregates plus fibrin) are laid down in small blood vessels ĺ ischaemia
and consumption of platelets and clotting factors ĺ bleeding
Acute: bleeding predominates

Chronic: clotting predominates

Causes:
Release of a substance into the circulation which initiates clotting

·Sepsis Endotoxins / exotoxins

Monocytes release a procoagulant tissue factor
· Mucin
Malignant neoplasms Thromboplastin-like substance
Procoagulant material in granules of malignant promyelocytes
Amniotic fluid
Products of conception act as procoagulant material
·Obstetric related Fat
Phospholipids
Trauma
·Head injury Burns
Surgery

·Massive tissue injury

Widespread damage to endothelial cells ĺ initiation of clotting

Autoimmune
Meningococcaemia
Riccketsial infection
Severe infections
Miscellaneous
Snake bite – Taipan, Tiger, Brown and Red-bellied Black snakes
Shock
Heatstroke
Vasculitis
Aortic aneurysm
Liver disease

158
 The laboratory investigation for DIC

The laboratory investigation should include:

Ɠ Coagulation tests aPTT, PT, thrombin time (TT)

Ɠ D-dimer

Ɠ Fibrin degradation products (FDP)

Ɠ Platelet count

Ɠ Haemoglobin

Ɠ Analysis of the blood smear.

These tests should be repeated over a period of 6–8 h because an initially mild abnormality can changed
dramatically in patients with severe DIC.

Common findings include:

Ɠ Prolonged PT and/or aPTT

Ɠ Platelet counts 100 x 109/L, or a rapid Ļin platelet numbers

Ɠ Schistocytes (fragmented red cells) in the blood smear

Ɠ ĹFDP - the most sensitive test for DIC.

(The diagnosis of DIC is unlikely in the presence of normal levels of FDP)

Ɠ ĹD-dimer. The D-dimer test is more specific for detection of fibrin (but not fibrinogen) degradation
products and indicates that the cross-linked fibrin has been digested by plasmin.
Ɠ ĻFibrinogen level

Because fibrinogen has a prolonged half-life, plasma levels diminish acutely only in severe cases of DIC.

Ɠ ĻAntithrombin III & plasminogen levels may occur in high-grade DIC

159
6. Renal Function Tests

Essential

Pre reading

¾Normal functions of the kidney

¾Normal anatomy of the kidney including the micro-anatomy of the nephron
¾Function of the juxtaglomerular apparatus
¾Normal urine: volume, pH, constituents such as: Tamm-Horsfall protein, urobilinogen
¾Abnormal urine: proteinuria, glycosuria, ketonuria, nitrites, increased numbers of cells + casts

In course
¾Understand the clinical relevance of GFR
¾Understand the staging of CKD using GFR results
¾Be able to list the common causes of CKD: diabetes, glomerulonephritis, hypertension
¾Understand the use of urea and creatinine levels in assessing renal function
¾Understand the clinical use of the urea:creatinine ratio using clinical examples of pre renal, renal
and post renal failure
¾Be able to list important causes of pre renal failure: dehydration, haemorrhage
¾Be able to list important causes of intrinsic renal failure: infection (glomerulo- and pyelonephritis);
drugs (NSAIDs); ischaemic insult (emboli ĺ vascular occlusion, haemorrhage ĺ hypotension and
acute tubular necrosis if prolonged)
¾Be able to list important causes of post renal failure: BPH
¾Understand the use of urinary PCR and ACR in assessing renal function
¾Understand the physiological basis of the common electrolyte disturbances seen in renal failure:
Na+, K+, phosphate, Ca++ and HCO3í
¾Understand ‘the anaemia of renal disease’
¾Understand the key clinical and biochemical features of nephrotic syndrome (proteinuria >3g/24hr;
hypoalbuminaemia; hyperlipidaemia; prothrombotic state; hypogammaglubulinaemia)

Important

¾ Understand the clinical relevance of plasma hypo – and hyperosmolality using the examples of
hyperosmolar non-ketotic diabetic coma, diabetes insipidus and SIADH
¾Understand the clinical relevance of 24 hour urine collection (protein measurement)

Desirable

¾ Be able to calculate the eGFR using the Cockcroft-Gault formula

160
 FUNCTIONS OF THE KIDNEY

1. Excretion of metabolic waste products e.g. urea and creatinine and drugs
2. Acid:base balance
3. Maintenance of normal electrolyte levels
4. Endocrine function – erythropoietin production
5. Hydroxylation of Vitamin D to its active form
6. Maintenance of stable blood pressure
7. Maintenance of normal plasma osmolality
8. Gluconeogenesis

The Nephron

161
162
Glomerular Architecture

163
Glomerular architecture
A. The glomerular capillaries form from a branching network of renal arteries, arterioles, leading to an afferent
arteriole, glomerular capillary bed (tuft), and a draining efferent arteriole
B. Scanning electron micrograph of podocytes that line the outer surface of the glomerular capillaries (arrow shows
foot process).
C. Scanning electron micrograph of the fenestrated endothelia lining the glomerular capillary.
D. The various normal regions of the glomerulus on light microscopy

164
 Substances exerting an important influence on the kidney

Renin

Pro-renin is formed in the juxtaglomerular cells in the afferent arterioles. When the BP falls, the slow flow
of filtrate along the tubules ĺ Ĺopportunity for sodium absorption.The low sodium content in the filtrate
passing along the DCT stimulates the conversion of pro-renin to renin, which enters the blood in the
afferent arteriole and is then carried systemically. Renin is an enzyme which converts angiotensinogen (a
plasma protein) to angiotensin I (10 amino acids); renin remains in the circulation for 30 – 60 minutes.
Renin also causes vasodilatation of the afferent arteriole of the glomerulus.
As angiotensin I passes through the lungs, the angiotensin-converting-enzyme (ACE) produced there and
present in the endothelial cells of the pulmonary capillaries, catalyses its conversion to angiotensin II (8
amino acids). The 2-amino acid peptide split off is known as hippuric acid.
Angiotensin II

1. Is a powerful vasoconstrictor; one of the arterioles it causes to constrict is the glomerular efferent
arteriole.
2. Promotes Na+ and H2O retention by the kidney, acting on the PCT
3. Stimulates aldosterone release from the adrenal cortex
4. May be converted to angiotensin (1 – 7) which stimulates release of ADH by the posterior pituitary.

Aldosterone

Aldosterone is a steroid hormone produced by the adrenal cortex. Its production is stimulated by
hyperkalaemia and by angiotensin II. It promotes absorption of Na+ and HO by the distal nephron, and K+ 2
excretion. In the event of an acute shortage of aldosterone (example: haemorrhage into the adrenal), we are able
to survive only a few days, becoming hypovolaemic, hypotensive and hyperkalaemic.
The more chronic manifestation of adrenal failure is known as Addison’s disease, 90% of cases being
autoimmune in aetiology, the other 10% caused either by infection with TB or secondary malignant
deposits in the adrenal glands.

Antidiuretic Hormone (ADH/Vasopressin)

ADH is secreted by the posterior pituitary in response to Ĺin plasma osmolality; the osmoreceptors in the
hypothalamus shrink in response to ĹNa+ levels in the blood, causing a message to be sent to the posterior
pituitary resulting in the release of ADH. ADH promotes water reabsorption in the collecting ducts. In the
absence of ADH, this part of the nephron is impermeable to water, as occurs in Diabetes Insipidus. ADH
(aka Vasopressin) also has a vasoconstrictor action.

165
166
 ASSESSMENT OF RENAL FUNCTION

BLOOD TESTS
Ɠ Urea
The urea level, on its own, is not a good marker for renal function
• The level only starts rising after 60% of renal function has been lost
• It is affected by several factors:
1. State of hydration
2. Amount of protein in the GIT •amount of protein in the diet

•GIT bleeding is in effect, a high protein meal

3. Liver function (Ļurea production in liver disease)

Ɠ Creatinine
The creatinine level is better as an indicator of renal function, as its level is affected (mainly) only by the
muscle mass of the patient. It is produced at a rate of ~ 10 mmol/day, from the breakdown of creatine &
phosphocreatine in muscle. However, when the GFR is low, the proximal convoluted tubule secretes
creatinine ĺ Ļ plasma level which does not reflect the Ļ GFR. Certain drugs (cimetidine, trimethoprim) can
block tubular secretion of creatinine ĺ Ĺ blood levels.

Ɠ Glomerular Filtration Rate (GFR)

The GFR is a good indicator of renal function
The Cockroft-Gault formula for Creatinine Clearance is reasonably accurate & can be estimated at the
bedside. (Creatinine Clearance Ł Glomerular Filtration Rate)
{140 – age} (yrs) x weight (kg)* x 1.04 (F); x 1.23 (M)
Creatinine Clearance = S-creatinine (ȝmol/L)
*The ideal body weight should be used if weight ĹĹ or ĻĻ

Staging of renal disease:

Impairment
Stage 1 GFR >90 ml/min; other evidence of renal disease minimal
Stage 2 GFR 60 – 89 ml/min mild
Stage 3 GFR 30 – 59 ml/min moderate
Stage 4 GFR 15 – 29 ml/min severe
Stage 5 GFR <15 ml/min/dialysis renal failure
Ɠ Electrolytes (venous blood)

Units Reference Range

Sodium mmol/L 135 - 145
Potassium mmol/L 3.2 – 4.5
Chloride mmol/L 100 - 110
Bicarbonate mmol/L 22 – 33
Calcium mmol/L 2.15 - 2.60
Phosphate mmol/L 0.7 – 1.4
Ɠ Osmolality (plasma) mmol/L 275 – 295
Calculated using the formula: 2 x Sodium + Urea + Glucose

167
Ɠ Urea:Creatinine Ratio
This ratio is calculated using the patient’s blood urea level divided by the patient’s serum creatinine level

e.g. Urea 6.0 mmol/l

Creatinine 100 ȝmol/L
Ratio = 6/0.1
= 60
(Normal range: 40 – 100)

The urea:creatinine ratio changes depending on the type of renal failure and may therefore be helpful in
diagnosis:
Ɠ Pre-renal Ĺratio*
Ɠ Intrinsic renal failure Ļratio
Ɠ Post-renal Ĺratio

*ĹRatio especially in volume depletion (dehydration, haemorrhage), LV failure, renal artery stenosis

In pre- and post-renal failure

Urea: The passage of the filtrate through the tubules is slow, and Ĺamounts of urea are reabsorbed (which
will be reflected as an increase in the blood urea level). Normally, 20 – 50% of filtered urea is reabsorbed
– in this situation >50 % reabsorption occurs.
Creatinine: Not only is creatinine not reabsorbed, it is actually secreted into the tubular lumen by the
tubular cells when the passage of the filtrate past the tubular cells is slow. This will be reflected in the
blood as a relatively low level of creatinine compared with the urea level, both of which are elevated but
with an Ĺratio of urea to creatinine.
In intrinsic renal failure
Due to the intrinsic damage to the kidneys, filtration is ĻĻ, so urea and creatinine accumulate rapidly in the
blood, with the creatinine level tending to rise proportionately > the urea level (Ļurea:creatinine ratio); this
is not a reliable test in this situation, however.
A s-creatinine level > 250 ȝmol/L has a 90% probability for intrinsic renal failure (as distinct from pre-
renal failure) and is a more reliable test here. (>2x normal creatinine level)

Other causes of change in urea:creatinine ratio

(Factors altering urea or creatinine levels per se, independently of renal failure)
ĹUrea
GIT bleed (Ĺprotein in GITĺĹurea production)
Tetracycline Ĺprotein catabolism
Sepsis "
Corticosteroids "

ĻUrea
Impaired liver function (Ļurea cycle)

Creatinine
Level depends on muscle mass. Muscle mass decreases with age, so relatively low levels of creatinine are
produced daily in the elderly, along with a steady decline in renal function with age i.e. creatinine blood
level will reflect a balance of Ļproduction and Ļrenal excretion.

168
URINE TESTS

Ɠ Urine examination
Characteristics of normal urine

Urine Volume 1 – 1.5 L/day

GFR 100 – 120 ml/minute (Ļ with age)
Protein 150 mg/day
Red Blood Cells < 5 /low power field
White blood cells < 10 /high power field
Urobilinogen 16 ȝmol/L
Osmolality 100 – 1000 mosm/kg
SG 1.002 – 1.025
pH 5 - 8
Creatinine 10 mmol/day
Urea 250 – 580 mmol/day
Sodium 0-150
Potassium 10 – 80
Calcium 2.5 – 7.5
Phosphate 15 - 50

• +ve test for blood on dipstix may = blood / haemoglobin / myoglobin

• >3 gm protein/day = nephrotic syndrome

Ɠ Quantifying Proteinuria

Measurement of albuminuria is helpful for monitoring nephron injury in many forms of CKD, especially
chronic glomerular diseases, as damaged glomeruli will leak protein. While an accurate 24 hour urine
collection is the gold standard for measurement of albuminuria, the measurement of albumin:creatinine
ratio in a first morning urine sample is more practical to obtain and correlates well (but not perfectly) with
24 hour urine collections.
Persistence in the urine of significant amounts of albumin usually signifies chronic renal damage.
Microalbuminuria refers to the excretion of amounts of albumin too small to detect by urinary dipstick.

Ɠ It is a good screening test for early detection of renal disease in particular

and
Ɠ may be a marker for the presence of widespread microvascular disease in general.
Just as the endothelium of the glomeruli has been so significantly damaged that it now ‘leaks’ albumin,
so the endothelium of many other vascular beds may be disrupted.

If a patient has a large amount of excreted albumin, there is no reason to perform an assay for
microalbuminuria, and a protein:creatinine ratio should then be performed.

Diabetic nephropathy
The onset of microalbuminuria marks a major increase in the risk of morbidity and mortality in the
diabetic patient.
The onset of microalbuminuria is a signal that diabetes management needs to be revised

169
Measurement of albumin in the urine: the Albumin:Creatinine Ratio (ACR)

Albumin is measured as a concentration or as a total quantity in the specimen. It is necessary

for the overall concentration of the urine or for the duration of the collection to be known. Otherwise
‘normal’ people could have apparently abnormal results because of very concentrated urine or a prolonged
collection.
This scaling is done by:
• creatinine, for albumin concentration
or
• timing for albumin excretion rate.
The amount of creatinine we produce and excrete is determined by our muscle mass.
Creatinine is a breakdown product of creatine that acts as an energy reservoir in muscle. The more muscle
we have, the more creatinine we produce.
Hence men, generally having a larger muscle mass, have higher plasma creatinine values and
urine creatinine excretion than women.

The albumin creatinine ratio (ACR) scales the albumin concentration according to the creatinine
concentration and allows for concentration or dilution of the urine.
Values for women are higher than men because creatinine excretion (the denominator) is lower.

In timing the urine collection scales for duration, the person voids before bed and notes
the starting time of the collection. Overnight all the urine produced is collected. On rising, the
person voids, collecting the urine and noting the time of completion. The laboratory calculates the
duration and scales the amount of urine in the specimen by time ĺ albumin excretion rate (AER ȝg/min).
Results are recorded as normo-, micro- or macro-albuminuria.

Microalbuminuria can only be detected by a laboratory or by a special urine dipstick (Micral).

Macroalbuminuria corresponds to proteinuria ( 500 mg/L of protein) and can be detected by the usual
urine dipstick
Macroalbuminuria is considered more indicative of overall kidney function (as opposed to
microalbuminuria detecting early damage limited to the glomerular endothelium).
Albumin:Creatinine ratio (mg/mmol) Normal Values
(Specimen: first voided morning urine)

Women Men

Normal 0–3.5 0–2.5

Microalbuminuria 3.6–35.0 2.6–25.0
Macroalbuminuria >35.0 >25.0

Measurement of total urinary protein – the protein:creatinine ratio (PCR)

• Protein Creatinine ratio (PCR) on a spot urine specimen (preferably first voided)

The value of the PCR is determined in exactly the same way as is the ACR. In this instance, total urinary
protein is assessed, not just albumin

The normal PCR is <15

The normal ACR is <3

170
Urine Specific Gravity

Urine specific gravity reflects the mass of 1 mL of urine compared with 1 mL of distilled water.
Normal values range between 1.001 and 1.035. In settings of poor perfusion or prerenal azotaemia,
urine specific gravity is high (e.g., 1.030), reflecting the kidney's ability to conserve sodium and water.
With loss of concentrating ability due to acute tubular necrosis, urine specific gravity resembles plasma
osmolarity (i.e., 1.010).

Urine Osmolality
Osmolality is a measure of the number of osmotically active particles in solution. It is one of the
major forces that move fluid throughout the body, especially in the kidney. Theoretically, urine
osmolality is physiologically superior to urine specific gravity as a test of renal function; however,
the same substances and conditions that affect urine specific gravity can also affect urine osmolality
A defective urinary concentrating mechanism tends to be one of the most consistent and lasting
tubular defects of ARF.
Specific gravity is a surrogate for osmolarity (normal range, 50 to 1000 mOsm/kg).

Urine osmolality as a test for distinguishing ATN from prerenal azotaemia

With urine osmolality values >500 mOsm, the positive predictive value for diagnosing prerenal
azotaemia ranges from 60% to 100%.
With a value less than 350 mOsm, the positive predictive value for diagnosing acute tubular necrosis
ranges from 69% to 95%.

Serum Creatinine Concentration

Creatinine, a cyclic anhydride of creatine, is a small molecule that is continuously released during
skeletal muscle protein catabolism.
Serum creatinine concentration remains the most used clinical tool to assess renal function. However,
serum creatinine concentration is only somewhat reliable as a sign of renal dysfunction, and GFR
may be reduced by as much as 75% before elevations reach abnormal levels.

171
 ACUTE RENAL FAILURE

AETIOLOGY - 3 ways in which acute renal failure can be caused:

1. Pre-Renal Causes (80% of cases)

Any cause of ineffective circulation ĺ poor renal perfusion and ĻGFR

•LV failure ĺ Ļcardiac output

•ĻCirculating blood volume ƕHaemorrhage
ƕDehydration
•ĻSystemic vascular resistance ƕSepsis
ƕLiver failure
•ĹRenal vascular resistance ƕHepatorenal syndrome
ƕRenal artery obstruction*
ƕRenal vein thrombosis**
2. Intrinsic Renal Disorders (10 – 15%)

•GlomerularleAsicountse GN ƕ IgA nephropathy

ƕ SLE
ƕ Post-infectious
ƕ Bacterial endocarditis
Ischaemia (any of pre-renal causes if inadequately treated)
⁄
•Tubular lesions
\
Nephrotoxins - Endogenous – Myoglobin
Haemoglobin
Calcium
Uric acid
- Exogenous - Aminoglycosides
Immunoglobulin light chains

leCsoionntsra st material

•Interstitial ƕ Reactions to drugs – NSAIDS, antibiotics etc

ƕ Autoimmune diseases - SLE/MCTD
ƕ Pyelonephritis
ƕ Infiltrations - lymphoma/leukaemia
•
Microvasculalresions ĺ nephropathy ƕ Vasculitis
ƕ Malignant hypertension
ƕThrombotic microangiopathies
ƕThrombo- and athero-embolism

3. Post-renal (5% – 10%)

Obstruction ĺ anuria

e.g. Urethral stricture Calculi

BPH / Ca prostate Tumourĺ compression of ureters
Ca Bladder Retroperitoneal fibrosis

172
*Renal artery obstruction:
ƕ Proximal part of the renal artery in ƃ>50 years (atherosclerotic basis)
ƕ Distal part of renal artery/intra-renal part in renal artery stenosis Ƃ20 – 50 years
These lesions cause chronic renal failure, as the obstruction impairs renal function over a period of time;
acute renal failure may be precipitated if there is development of a thrombus at the site of the stenotic
lesion.

**Conditions associated with renal vein thrombosis:

Trauma
Extrinsic compression e.g. lymph nodes, tumour, AAA
Invasion of renal vein by renal cell carcinoma
Dehydration (especially in infants)
Nephrotic Syndrome
Pregnancy / oral contraception

***Thrombo / athero-embolism may occur

ƕduring angiography
ƕfrom intra-cardiac lesions – atrial ƕ thrombus secondary to AF
ƕatrial myxoma
- ventricular aneurysm ventricular ƕ post MI - mural thrombus,
ƕfrom atheromatous lesions of the aorta

173
Summary of features of acute renal failure (ARF)

History and Presentation

Pre-Renal
Variable, depending on the cause. May be preceded by a catastrophic event
(e.g. post-surgical haemorrhage) ĺ ĻBP.
Urine output Ļacutely, with a concomitant Ĺin plasma urea and creatinine levels.
If the Ļrenal perfusion can be rectified timeously, the renal failure may be rapidly reversed.
Intra-Renal
Many different causes affecting various parts of the nephron, so presentation depends on the cause e.g.:
Ɠ Glomeruli glomerulonephritis
Ɠ Tubules toxins, ATN (acute tubular necrosis)
Ɠ Interstitium infection
Ɠ Vessels (small) vasculitis, thrombo-embolism
Commonest cause is ATN following a pre-renal situation, in which blood supply to tubules is inadequate
ĺ tubular cell death.
Post-Renal
Ɠ May be a history of difficulty in passing urine.
Ɠ There may be enlarged kidneys on ultrasound if bilateral ureteral obstruction
Ɠ An enlarged bladder may be palpable if a urethral obstruction is present.

Urine Volume
Pre-Renal
Urine volume Ļ due to hypoperfusion of glomeruli. May be anuria if patient shocked ++ or bilateral
vascular occlusion as in dissecting aortic aneurysm.
Intra-renal
There may be oliguria (50 – 400ml/day) or urine volume may be relatively normal ( 2.4L/day); the
oliguric phase lasts on average 10 – 14 days, and may be followed by a short diuretic phase (due to
persisting inability of tubules to concentrate the urine), and then a gradual return to normal urine output.
Post-renal
Anuria (<50ml/day) occurs most commonly in this situation.

Urinalysis
Pre-renal
Unremarkable – urine normal or near normal (no casts/Ĺcells).
ĻUrinary sodium due to renin-aldosterone system activation & relatively high urinary urea (compared to
intra-renal failure) because kidney function normal, just Ļperfusion pressure ĺ ĻGFR, so urea still filtered
but at Ļrate.
Intra-renal
Ɠ Haematuria and red cell casts in glomerulonephritis/vasculitis
Ɠ Epithelial casts ( “muddy brown casts”) & granular casts in ATN
Ɠ Eosinophiluria in acute interstitial nephritis
Ɠ Pyuria & white cell casts in infection e.g.pyelonephritis

Post-renal
Urine normal or near normal. Possibly Ĺwhite cells (infection) or red cells (trauma from calculi)

174
Blood Tests (Common to pre-, intra-, and post-renal)
Urea Daily Ĺ of 3.5 – 5.0 mmol/L/day
Creatinine Daily Ĺ of 90 - 180 ȝmol/L/day
Sodium Normal /Ļ if fluid overload present (as may readily occur if patient oliguric)
Potassium Ĺ (Ļ filtration & urinary excretion)
Calcium Ļ / Normal (ĻActive Vit D, secondary hyperparathyroidism)
Phosphate Ĺ (Ļ filtration & urinary excretion, and secondary hyperparathyroidism)
BicarbonateĻ Due to metabolic acidosis (kidney unable to excrete H+ ions)
(Bicarbonate level usually in range of 15 – 20 mmol/L)
FBC
Normocytic anaemia (ĻEPO, uraemic toxins)

Imaging
Renal ultrasound
To assess kidney size – if small, indicates chronic renal disease; may be Ĺ in size if obstruction present

Abdominal Xray.
90% of renal calculi are visible on abdominal Xray

DIALYSIS – indications in ARF:

In ARF often used prophylactically to tide patient over till normal renal function returns.

*Epithelial casts are derived from tubular lining cells that are desquamated. This occurs particularly in
acute tubular necrosis ĺ muddy, brown casts.
Granular casts have a core derived from filtered plasma proteins to which cellular debris may be added,
such as degenerating red cells or white cells.
Hyaline casts are a normal occurrence and are derived from Tamm-Horsfall protein. They are formed
mainly in the collecting ducts and there may be Ĺnumbers in dehydration.

Daily Urine Composition

Normal Acute renal failure

Pre-renal Intrinsic
Volume
ml/day 1000 - 1500 <400 <400
Urea
mmol/day 350 (ave) 250 85
Creatinine
mmol/day 9 – 13 >9<9
Sodium
mmol/day 100 5 25
Osmolality
mosm/L 100 - 1000 >500 <350

175
 CHRONIC KIDNEY DISEASE (CKD)

AETIOLOGY (Commonest) 1. Diabetes mellitus

2. Hypertension
3. Chronic Glomerulonephritis

CKD may develop relatively rapidly over months or progress slowly over a period of years.

Eventually only a few nephrons remain functional, so these few have to handle all the filtered water and
solutes. There is a high solute load as there is retention of waste products in the blood e.g. urea.
This high solute load causes an osmotic diuresis (similar mechanism to that which occurs in the glycosuria
of diabetes mellitus). The damaged nephrons lose their concentrating ability, with the result that large
volumes of urine isotonic with plasma are voided. The urine volume is usually <3L / day.

A cardinal feature of chronic renal failure is nocturia, which is a reflection of the diuresis caused by the
high solute load.

1. Diabetic Nephropathy
Diabetic nephropathy is one of the commonest causes of endstage renal failure.
It is the second commonest cause of death in patients with diabetes mellitus, myocardial infarction being
the commonest.
Albuminuria may already be present in type II diabetes at time of diagnosis, owing to the prolonged
asymptomatic period of hyperglycaemia before diagnosis.

Time course of development of diabetic nephropathy

The relationship of time from onset of diabetes, the glomerular filtration rate (GFR), and the serum creatinine
are shown

Pathogenesis of diabetic nephropathy:

3 lesions:
1. Glomerular
2. Vascular
3. Infection (particularly necrotising papillitis)
Glomerular lesions consist of:
i. Basement membrane thickening, due to deposition of AGEs in glomerular capillaries. Although the BM
is thickened, it is leaky, and allows albumin to filter through. This occurs within a few years of onset of
hyperglycaemia.
ii. Glomerulosclerosis; AGEs are deposited in the mesangium and the matrix expands and the mesangial
cells proliferate ĺ diffuse or nodular glomerulosclerosis. Because of the expansion of the mesangium, the
glomerular capillaries are squashed up at the outer edge of the glomeruli, and this ĺ compression of the
efferent arterioles and resultant hypoperfusion of tubules, which derive their blood supply from the
efferent arterioles.

176
 The nodular form is characteristic of diabetic nephropathy & is known as the Kimmelsteil-Wilson lesion.
(PAS +ve, consisting of mucopolysaccharides, lipids, fibrils & collagen). This lesion is seen in ~35% of
diabetic patients.
Vascular lesions
Arteriolosclerosis of both afferent & efferent arterioles due to accelerated atherosclerosis. The
arteriolosclerosis of the efferent arterioles is characteristic of diabetic nephropathy.*

Ɠ Nodular mesangial expansion (Kimmelstiel-Wilson lesions)

Ɠ Prominent glomerular basement membranes
Ɠ Arteriolar hyalinosis of both afferent and efferent arterioles

Infection - Necrotising papillitis

This lesion is also characteristic of diabetic nephropathy, & is caused by the combination of Ĺ
susceptibility to infection as well as tubular & interstitial ischaemia, as discussed above.
(Due to the glycosuria, glucose is absorbed into the tubular cells, where it is converted to glycogen &
stored. This does not appear to cause any functional impairment.)
Treatment of early diabetic nephropathy

ƒ Strict BP control: ACE inhibitors angiotensin II blockers ĺ vasodilatation of efferent arteriole ĺ Ļintra-
glomerular pressure and better perfusion of tubules.
Sƒ trict glucose level control to limit AGE deposition in basement membrane and mesangium
*Causes of accelerated atherosclerosis in Diabetes Mellitus:

1. 50% of diabetics have ĹLDL, ĹTG, ĻHDL – due in part to Ļactivity of lipoprotein lipase, in part to
Ĺproduction because of plentiful supply of FA secondary to lipolysis.
2. Even when lipoprotein levels are normal, they are functionally impaired due to glycosylation, and may
be deposited in tissues more readily than normal.
3. Deposition of AGEs in intima of blood vessels and cross linkages between the molecules ĺ entrapment
of LDL with deposition of cholesterol to form plaques.
4. ~70% Diabetics are hypertensive ĺ Ĺpropensity for developing atherosclerosis.

2. Hypertension
Arteriolosclerotic lesions of afferent and efferent arterioles and the glomerular capillary tufts are the most
common renal lesions in hypertension and result in progressive Ļ in GFR and tubular dysfunction.
Proteinuria and microscopic haematuria occur because of glomerular lesions.
The characteristic pathology is in the afferent arterioles, which have thickened walls due to deposition of
homogeneous eosinophilic material (hyaline arteriolosclerosis).
Narrowing of vascular lumina results with consequent ischaemic injury to glomeruli and tubules.

177
 3. Chronic Glomerulonephritis
IgA Nephropathy

This is the most common form of glomerulonephritis worldwide, being the culprit in up to 40% of cases.
The pathogenesis is incompletely understood. IgA production by plasma cells is increased and
glycosylation of IgA may occur with impairment of IgA clearance.

IgA is deposited in glomeruli (top) and is evident on immunofluorescence (bottom) of renal biopsy specimens
Most cases are idiopathic
Some are associated with Henoch-Schonlein purpure (considered to be part of the same disease process)
Occasionally found in association with systemic diseases such as:
Chronic liver disease
Crohn’s disease
Ankylosing spondylitis
Presentation
Typically presents 24 – 48 hours after an URTI or gastrointestinal infection, vaccination or strenuous
exercise, with gross haematuria. The condition tends to smoulder for decades with intermittent
exacerbations of haematuria and gradually declining renal function. Up to 50% of patients develop
endstage renal disease after 20 years.
Treatment
Observation
ACE inhibitors
Steroids

178
Summary of features of chronic kidney disease
History and Presentation
History of chronic GN, DM, HT
Onset is insidious. As GFR progressivelyĻ, urea and creatinine levels in the blood Ĺaccordingly.
Renal excretion of creatinine continues at a constant rate of 10 mmol/day
(Urinary creatinine excretion = GFR x plasma creatinine; as GFRĻ, creatinine plasma levelĹ and
amount of filtered creatinine remains unchanged)
Early CKD
Symptoms are minimal early on. Tiredness and Ļmental acuity may occur.
In the blood, sodium and water balance are maintained as remaining functioning nephrons fail to
reabsorb usual amounts of sodium ĺ Ĺurinary excretion. (So even though Ļfiltration of sodium,
Ĺexcretion ĺ sodium balance)
Tubules lose their concentrating ability, so urine volume is maintained. The SG of the urine approaches
that of plasma (1.010) = isosthenuria
Nocturia is typical, as tubules fail to reabsorb water due to Ļconcentrating ability, and high solute load ĺ
solute diuresis (high levels of urea filtered because high levels in the blood)

Advanced CKD
Symptoms:
STiirgendsn: ess, anorexia (Ĺleptin), nausea, vomiting, pruritus
ƕ Hypertension in >80% ·Ĺ fluid balance
·Ĺ renin in some patients
ƕ Fluid overload. As number of mal-functioning nephrons Ĺ to 75%, kidney is unable to excrete
sufficient water (and solutes)
ƕ Sallow skin, uraemic frost (rarely seen)
ƕ Cardiomyopathy secondary to hypertension/IHD ĺ pulmonary oedema /CCF
ƕ Pericarditis

Urinalysis
Proteinuria
Broad casts
SG 1.010

Blood Tests
·Similar results to those seen in ARF
·Lipid Screen: ĹTG
Total cholesterol normal
Ļ HDL
Ĺ oxidised LDL
Ĺ Lp a
Ĺ Homocysteine

Imaging
Xray: Renal osteodystrophy
Ultrasound: Bilateral shrunken kidneys <10cm in length
Doppler Renal artery stenosis

DIALYSIS – indications in CRF:

ƒ GFR < 10 ml/min
ƒ GFR < 15 ml/min in Diabetic nephropathy
ƒ Uraemic signs & symptoms severe e.g. vomiting, tiredness, pericarditis, pulmonary oedema

179
 ACUTE VS CHRONIC RENAL FAILURE

As the blood chemistry may be indistinguishable between acute and chronic renal failure, and a history
may not be available, it may be difficult to decide whether a patient’s renal failure is chronic or of more
recent onset. Some characteristic features of acute versus chronic renal failure follow.

FINDING COMMENT

Prior known Ĺs-creatinine Most reliable evidence of CRF

Renal Ultrasound:
Small kidneys High association with CRF
Normal/enlarged kidneys
May be associated with ARF and some forms of CRF e.g.
PCKD
Oliguria, daily Ĺs-creatinine and urea Probably ARF or ARF superimposed on CRF

Band keratopathy Probably CRF

No anaemia Probably ARF or CRF from PCKD

Severe anaemia, Ļcalcium, Ĺphosphate Possibly CRF but seen also in ARF

Subperiosteal erosions on Xray Probably CRF

Symptoms/signs of fatigue, nausea, High association with CRF

pruritus, nocturia, hypertension
CRF = chronic renal failure
ARF = acute renal failure
PCKD = polycystic kidney disease

180
 Laboratory evaluation of urine and blood in the diagnosis of renal failure –
a comparison between acute and chronic renal failure

Acute renal failure is suspected when urine output falls or serum urea and creatinine rise, in the setting of
an acutely ill patient with any of the predisposing causes.
A progressive daily rise in serum creatinine is diagnostic of ARF. Serum creatinine can increase by as
much as 180 ȝmol/L per day.
The most reliable evidence of chronic renal failure is a known prior Ĺin serum creatinine
Azotaemia is elevation of urea and creatinine
Uraemia is azotaemia accompanied by clinical signs and symptoms of renal failure.

Urine Volume Pre-renal 50 – Urine Chemistry Blood Chem / Haem

Ĺ Urea
400ml/day Na <20mmol/L* Ĺ Creatinine
Urea >250mmol/L
Uraemia U/P osmolality >1.5
Oliguric phase (ĻĻGFR) Na > 40mmol/L
Acute Ļ Na (dilutional)
Renal Ĺ K** (1 - 6wks) ĻUrea < 160mmol/L
Failure Ĺ Phosphate50 – 400ml/day U/P osmolality < 1.5
N/Ļ Calcium ********** *********
Ĺ Urea Recovery phases:
Ĺ Creatinine §Diuretic phase (3-7 days)
Ļ Bicarbonate 3 – 5 L/day
N/ĻHb*** Post diuretic phase (several days)
Urine vol Ļ to 1- 1.5L/day

Chronic N/Ļ Na Nocturia ĹUreaĺhigh solute load

Urine vol proportional to intake ĹProtein
Renal N/Ĺ K
Failure Ĺ PhosphatUe/ P osmolality 1.0
N/Ļ Calcium (isosthenuria)
§§ U-osmolality is normally Ĺ Urea, ĹCreatinine
2.5 – 4x > P- osmolality Ļ Bicarbonate
ĻĻ Hb ĻUrine volume ĻProteinuria

Endstage ĻNa
Chronic ĹK
Renal ĹĹ Phosphate
Failure ĻĻ Calcium
ĹĹ Urea, ĹĹCreatinine
ĻĻ Bicarbonate
ĻĻ Hb
* Aldosterone effect. There is no intrinsic renal damage at this stage, so urea is filtered as usual ĺ high osmolality
of the urine
**ĹK+ usually secondary to Ļfiltration, diuretics/K+ in diet/blood transfusion/acidosis
***Anaemia develops once 80% renal function has been lost
§Diuretic phase of ARF occurs as glomerular function recovers while tubular function lags behind, so filtration
occurs but concentrating ability still impaired.
§§ U-osmolality is usually 500 – 800 mmol/L (Normal range: 100 – 1000 mmol/L)

181
Nitrogen-containing substances which we routinely measure and which accumulate in renal failure
are:

1. Urea – derived from NH3 (= ammonia, the end-product of protein breakdown)

NH2
\
C=O
NH2/

2. Creatinine

C = NH - derived from creatine and creatine phosphate in muscle

/|
/ NCH3
NH
\| |
CO
\ CH2
3. Uric Acid

- derived from metabolism of purines - adenine and guanine

Other substances which accumulate in renal failure and which we measure routinely are some of the
electrolytes, namely:
Potassium – our daily ingested potassium = ~ 100mmol. Most of this is excreted by the kidney, so in
renal failure, hyperkalaemia readily develops.
Phosphate – 90% of phosphate is excreted by the kidneys. ĹPTH levels in response to hypocalcaemia
cause further increases in the phosphate level, as osteoclastic activity in bone ĺ calcium and phosphate
being released into the circulation.

Magnesium – level increases in renal failure.

Levels of some electrolytes may be normal or reduced:

· Sodium (normal) - Ĺurinary excretion

· Calcium (decreased) due to Ļactive Vitamin D
· Bicarbonate (decreased) – used up in buffering H+, which accumulates due to Ļproduction of NH3 by
the kidneys in renal failure.

182
 Uraemic toxins and atherosclerosis in uraemia

Uraemic toxins
A variety of solutes are retained in renal failure, and may have a toxic effect on the tissues ĺ clinical
syndrome of uraemia.
These include:

Ɠ Small molecules e.g. urea, which degrades ĺ ammonia + cyanate

Ɠ Larger molecules “middle molecules” e.g. ȕ2- microglobulin (one of the MHC proteins)

Ɠ Other solutes: · protein derivatives (proteins damaged by oxidation or cyanate

e.g. oxidised LDL
lipoprotein a
· cytokines
· homocysteine (derived from methionine)
· ADMA (derived from arginine - asymmetric dimethyl arginine)
· Ig light chains
· Leptin, angiogenin, phosphate, oxalate, indoles, skatoles, hippuric acid*

Atherosclerosis in uraemia
Development of atherosclerosis is accelerated in CRF due to the following:
· ĹLevels of bad things ĺ damage to vessel walls & hyperlipidaemia

· ĻLevels of good things, which normally protect our vessels and promote sensitivity to insulin.
( Ļsensitivity to insulin ĺ ĹVLDL)
ĹBad things ĻGood things

ADMA Nitrous oxide

ROS Adiponectin
Cyanate (OCNǦ̌ ) L-carnitine
Homocysteine
Cytokines
ĹCa:PO4 product

Bad things
ADMA inhibits nitrous oxide synthase, the enzyme required for NO synthesis in the endothelium; NO is
vasoprotective ĺ vasodilatation and promotes sensitivity to insulin
ROS (Reactive oxygen species) - derived from oxygen neutrophil activation
e.g. hydrogen peroxide H2O2 Ĺ Ļ
hydroperoxyl radical HO2Ǧ̌ ROS
ĹLevels of ROS in CRF due to:
· Dialysis membrane ĺ neutrophil activation ĺ ROS
· Fe++ liberated by RBCs which have shortened lifespan in CRF (abnormal shape, ĻL-carnitine) ·
ĻIngestion of antioxidants (poor appetite in CRF due to Ĺleptin)

183
 Cyanate (OCNǦ̌ )
NH2
\
/ C=Oĺ NH3 + OCNǦ̌

2
NH

Cyanate damages proteins ĺ accumulation of abnormal proteins, such as lipoprotein a, a very atherogenic
type of LDL, in which an extra protein (similar in structure to plasminogen) is bonded to the apo-protein
of LDL.
Homocysteine · damages vessel walls
· promotes thrombosis
· Ļinsulin sensitivity
Cytokines produced by activated neutrophils, promote hepatic production of CRP, which damages
endothelium
Ca:PO4 product – as calcium level falls due to Ļactive vitamin D, PTH levelĹ ĺ osteoclast activation &
Ĺlevels of both calcium and phosphate; when the Ca:PO4 product reaches a critical level, calcium starts
precipitating out and deposition in vessel walls ĺ sclerosis

Good things

N· ĺi tvraosuosd oilxaitdaeti on
·Ĺsensitivity to insulin
A· idnihpiobnitesc mtionn ocyte adhesion to endothelium
· anti-inflammatory
· Ĺsensitivity to insulin

L-carnitine · required for ȕ-oxidation of fats; absence ĺ ĹVLDL production

· required for healthy erythropoiesis; absence ĺ Ļred cell survival

*Leptin is produced by adipose tissue, binds to neurones in the hypothalamus (satiety centre) relaying the
message that we are satiated
Angiogenin, a protein that binds to endothelial cells, is endocytosed and promotes new vessel formation
Indole, a product of bacterial breakdown of tryptophan in the GIT, gives our faeces its characteristic
odour.
Skatole (methylated indole) is also malodorous
Hippuric acid is a peptide derived from the conversion of angiotensin I ĺ II

184
 SIADH

(Syndrome of Inappropriate Secretion of Antidiuretic Hormone)

SIADH is an important cause of hyponatraemia. This syndrome is caused either by inappropriate secretion
of ADH from the posterior pituitary gland or by ectopic production of ADH by a tumour. Example:
Carcinoma of the Lung
The excessive reabsorption of water in the distal nephron continues in the face of a dilute ECF, the
concentration of both sodium and urea in the plasma being predominantly affected (decreased). This will
cause the plasma osmolality to fall, as can be seen by the formula:

Plasma Osmolality = 2x Sodium + Urea + Glucose (mmol/L)*

The concentration of the other electrolytes in the plasma is usually unaffected.

The diagnosis is made by comparing plasma osmolality with urine osmolality; in the normal course of
events, when plasma osmolality falls, urine osmolality will also fall, as ADH secretion is inhibited by
hyponatraemia. (Example: In psychogenic polydipsia)
In SIADH, urine osmolality is inappropriately high (concentrated urine because ĹĹreabsorption of water),
in the face of a Ļplasma osmolality.
Diagnosis confirmed when U- osmolality > P- osmolality or U- osmolality > 200 mmol/L, in the face of ĻP-
osmolality.
Common causes

Drugs: tricyclic antidepressants, carbamazepine, phenothiazines, omeprazole, chlorpropamide, vincristine,

vinblastine, cyclophosphamide, clofibrate, haloperidol, angiotensin converting enzyme inhibitors,
narcotics, nicotine, monoamine oxidase inhibitors, SSRIs, and many others

Post-operative stress caused by surgery, use of a mechanical ventilator, or anaesthetic agents

CNS disturbances due to: infections (meningitis, brain abscess)

stroke
trauma
neurosurgery
Pulmonary disorders: pneumonia, tuberculosis, emphysema, status asthmaticus

Rare causes

Malignant disease
•Neoplasm
in the lung (most commonly small cell carcinoma), duodenum, pancreas, olfactory
•Lnymeuprohbolmasat oma, bladder, prostate, thymus, or brain
•Leukaemia
•Mesothelioma
•Ewing's sarcoma
Psychoses

Hormone administration
: vasopressin or oxytocin

*Normal P-Osmolality: 275 – 295 mmol/L

185
186
 Nephrotic Syndrome
Definition: · Proteinuria of 3.0 g/day ·
Hypoalbuminaemia
· Oedema
· Hyperlipidaemia
Consequences:
Proteinuria
Damage to the glomerular basement membrane results initially in leakage of albumin into the tubules ĺ
hypoalbuminaemia. As the condition progresses, higher molecular weight proteins are lost in the urine and
the urinary protein losses can be massive.
Hypercoagulable state
Nephrotic patients often have a hypercoagulable state, and are predisposed to DVT, pulmonary embolism
and renal vein thrombosis. There is loss of urokinase and anti-thrombin 3 (ATT) in the urine, and Ĺlevels of
factor VIII, fibrinogen and platelets in the blood.
Hypogammaglobulinaemia
These patients are also prone to infections, as they develop hypogammaglobulinaemia due to
Immunoglobulin loss in the urine.
Oedema is often the presenting feature and is due in part to Ļoncotic pressure due to hypoproteinaemia.
Some patients are resistant to the effects of atrial natriuretic peptide, and reabsorb inappropriate amounts
of sodium and water in the tubules, and may become oedematous even when the serum albumin is not
very low.
Hyperlipidaemia is contributed to by both ĹTG and total cholesterol, mainly due to ĹLDL-cholesterol. It is
hypothesised that hepatic lipoprotein and albumin production are linked, and the Ĺhepatic synthesis of
albumin in response to Ļplasma levels, results also in Ĺhepatic synthesis of lipoproteins.
Another hypothesis is that a protein important in regulation of lipoprotein synthesis is lost in the urine in
this syndrome, resulting in disordered hepatic production of lipoproteins.
There is Ĺhepatic production of cholesterol and manufacture of LDL de novo in the liver occurs. ĻActivity of
LCAT and also of lipoprotein lipase (LPL) is evident.
Loss of heparan sulphate in the urine means that the attachment of lipoprotein lipase to the endothelium is
impaired, and the free LPL is therefore easily lost in the urine. ĹCirculation time of VLDL results, with ĹTG
level.
ĹLevels of Lp(a) is also often found and this contributes to the tremendous hyperlipidaemia which is a
hallmark of this condition.
Causes:
*Glomerulonephritis Membranous, minimal change, focal segmental,
proliferative etc
Systemic diseases *Diabetes, SLE, *Amyloidosis, Sarcoidosis, vasculitic-
immunologic diseases e.g. polyarteritis nodosa
Infections Bacterial (streptococcal, syphilis, SBE)
Viral (Hepatitis, HIV, infectious mononucleosis, CMV)
Parasitic (malaria, toxoplasmosis, schistosomiasis, filariasis)
Drugs Gold, mercury, NSAIDs, lithium, heroin

Neoplasms Hodgkin’s disease, solid tumours

Hereditary Alport’s syndrome, Sickle cell anaemia, familial nephrotic

syndrome

Other Pregnancy, massive obesity, renal artery stenosis, transplant

rejection

*Most common
187
 ELECTROLYTES

Potassium
Hyperkalaemia Hypokalaemia

Metabolic acidosis Metabolic alkalosis

Renal failure D&V / Laxative abuse
Addison’s diseaseSteroid Rx / Conn’s syndrome
Diuretics e.g. ACE inhibitors Diuretics e.g. Frusemide
Rhabdomyolysis Liquorice
Burns Villous adenoma
Massive blood transfusion

ƕAcute metabolic acidosis ĺĻfunction of Na:K pumpĺĻIC K+ and ĹECF K+; in the kidney, because the
concentration in the tubular cell isĻ, there is reduced diffusion ĺ the tubular lumen ĺ accumulation of
K+ in the body.
ƕRenal failure means that amount of K filtered is ĻĻ and so accumulates in the ECF
ƕIn rhabdomyolysis, K+ is released as the cells lyse
ƕThe mechanism by which metabolic alkalosisĺ ĻK+ is incompletely understood; however, there is an
influx of K+ into the cells, including the tubular cells, and Ĺdiffusion across the tubular membrane into
the lumen, resulting in Ĺloss in the urine.
ƕThe Ĺurine flow rate resulting from a diuretic stimulates K+ secretion ĺlumen of the DCT and loop of
Henle.
ƕLiquorice has an aldosterone-like effect

ECG changes of hyperkalaemia K+ >5.5 mmol/L

(Usually asymptomatic until ECG changes occur):
Short QT interval
Tall T waves
ST elevation
Arrhythmias – sinus bradycardia, nodal/ventricular arrhythmias
Widened QRS
P wave disappears
Finally, QRS ĺ sine wave and asystole / ventricular fibrillation

ECG changes of Hypokalaemia K+ <3.5 mmol/L Signs and Symptoms

1dsrdt/2/3degree
n heart block Muscle weakness, cramps, fasciculations
T wave flattening Paralytic ileus
ST depression ĻVentilation
Prominent U waves ĻBP
APBs/VPBs Rhabdomyolysis
Atrial/ventricular tachyarrhythmias Nephrogenic diabetes insipidus
Potentiation of adverse effects of Digoxin (tubules damaged & cannot respond to ADH)

Normal renal handling of potassium

We daily ingest 100mmol K+, the majority of which is excreted by the kidneys

Should we be hypo- or hyperkalaemic, K+ may be reabsorbed from the filtrate as it passes through the
DCT and collecting duct or secreted into the filtrate here in greater amounts to restore potassium balance..

188
 Sodium

Hypernatraemia Hyponatraemia
ĹNa Conn’s syndrome 2
ĻH2O •Dehydration ĻĻNa:ĻHO •D&V
•Diuretics
•Diabetes Insipidus •DMĺosmotic diuresis
•Addison’s Disease
Normal Na:ĹH2O •ĹADH e.g. Ca bronchus (SIADH)
•Psychogenic polydipsia
ĹNa: ĹĹH2O •cardiac failure
•renal failure
•liver failure
•nephrotic syndrome
Hyponatraemia is the commonest electrolyte abnormality in the elderly and is associated with a
high mortality, because of the diseases associated with it.
Renal handling of sodium and water

Renal Na+ excretion = amount filtered ʊ amount reabsorbed

65% of filtered electrolytes (including Na+) are reabsorbed in the PCT. Here Na+ binds to a carrier
protein and enters the tubular cell, at the same time as H+ leaves the cell ĺ tubular lumen, the energy being
derived from a diffusion gradient for Na+ having been created by the Na:K ATP-ase pump, situated in the
contralateral wall of the tubular cell.
As the filtrate enters the Loop of Henle, permeability to water ĹĹ and permeability to electrolytes Ļ.Thus
the filtrate becomes concentrated here.
As the filtrate passes into the ascending limb, permeability to waterĻĻ and this is the status quo till the
distal end of DCT is reached.
Once the filtrate reaches the thick part of the ascending limb of the Loop of Henle, active reabsorption of
electrolytes takes place and continues till it reaches distal DCT.
In distal DCT and collecting ducts, ADH exerts its effect and promotes reabsorption of water. The level of
ADH is dependent on the osmolality of the blood.
It is in this area of the nephron that aldosterone has its effect too, enhancing Na+ and water reabsorption
and promoting K+ excretion. The stimulus for aldosterone secretion (via renin) is a fall in BP detected by
the JGA cells as well as a decreased level of sodium in the filtrate; hyperkalaemia also stimulates
aldosterone release.

Effective osmolality of a solution is to its Na content.

Normal plasma osmolality = 275 – 295 mmol/L

189
 Calcium

Hypercalcaemia Hypocalcaemia

Common: Parathyroidectomy
Hyperparathyroidism (adenoma) 1º Hypoparathyroidism
Malignancy Vit D deficiency (CRF/Ļsunlight)
Rare: Acute pancreatitis
Sarcoidosis Pseudohypoparathyroidism
Paget’s disease Severe alkalosis
ƕ The hypercalcaemia of malignancy is caused by a PTH-related peptide
ƕ Sarcoidosis ĺĹVit D activity. (Also ĹACE levels)
ƕ Paget’s disease ĺĹALP and osteoclastic activity in bone.
ƕ Calcium is chelated by products of lipolysis occasioned by release of pancreatic lipase in acute
pancreatitis
ƕ In pseudohypoparathyroidism, there is Ļresponsiveness to PTH
Calcium
41% calcium is bound to plasma
proteins 9% is bound to citrate and other
anions 50% occurs as free ionised
calcium
Hypercalcaemia
Is frequently asymptomatic
GIT symptoms Renal symptoms CNS symptoms

Constipation Polyuria Emotional lability

Anorexia, nausea, vomiting Polydipsia Confusion
Abdominal pain Nocturia Delirium
Ileus Renal calculi/nephrocalcinosis Psychosis
Peptic ulcer disease Stupor/coma
Pancreatitis
Muscle weakness

ECG: shortened QT interval

Hypocalcaemia

Is frequently asymptomatic
Neuromuscular irritability CNS symptoms Cataracts
Muscle cramps Depression Chvostek’s sign
Tetany Dementia Trousseau’s sign
Laryngospasm
Psychosis
Convulsions Papilloedema
ECG: prolonged QT interval

190
 Phosphate

ĹPhosphate levels ĻPhosphate levels

Renal Failure Critical illness

Massive cell necrosis especially ischaemic Alcoholism
bowel (intracellular anion) Diuretics
Metabolic acidosis Metabolic alkalosis
1˚ Hyperparathyroidism

ƕĻPhosphate levels post DKA and severe burns

ƕ10% patients admitted for alcohol-related illness have Ļphosphate levels
Phosphate 20% is intracellular (the main IC anion). Binds reversibly to many compounds
such as. ATP, ADP, phosphocreatine and is important in nucleic acid synthesis
80% is in bone bound to calcium
(Phosphorus is present in many foods, so dietary deficiency is very rare.)

Magnesium

ĹMg levels ĻMg levels

Renal failure Alcoholism

1˚ Hyperparathyroidism
Diuretics
Diarrhoea
ƕPatients in renal failure who ingest Mg-containing drugs (e.g. antacids) develop ĹMg levels
ƕPatients who are alcohol dependent, develop ĻMg levels due to poor intake and Ĺrenal excretion
Magnesium Functions as a catalyst in reactions involved in carbohydrate
metabolism 65% occurs in bone
35% is intracellular

Chloride

Ĺ Chloride Ļ Chloride
Normal anion gap acidosis: Metabolic alkalosis
(ĻBicarb = ĹChloride) (ĹBicarb = ĻChloride)
Iatrogenic - Ĺvolumes NaCl administered iv Vomiting
Diarrhoea
Chloride ion is very obliging – he likes to please, so:

When bicarb goes down, chloride goes up (to maintain electrical neutrality)
When bicarb goes up, chloride goes down.
When acidosis is present: ĹH+ ĹK+ ĹCl ¯ĹPO4 (ĻHCO3)¯

When alkalosis is present: ĻH+ ĻK+ ĻCl ¯ĻPO4 (ĹHCO3)¯

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 NORMAL VALUES
Full Blood Count (FBC) UNITS REFERENCE RANGE

Haemoglobin g/L 115 – 160 F 135

– 180 M x 109 /L 4.0
White Cell Count – 11.0 x 109 /L 140 -
Platelets 400 0.33 – 0.47 F
Haematocrit 0.35 – 0.51 M x
1012 /L 3.8 - 5.2 F
Red cell Count 4.5 - 6.0 M
fL 80 - 100
MCV pg/cell 27 – 33
MCH % 0.5 – 2.0
Reticulocyte Count

Differential count

Neutrophils x 109 /L 2.0 – 8.0

x 109 /L 1.0 – 4.0
Lymphocytes x 109 /L 0.1 – 1.0
Monocytes x 109 /L
Eosinophils < 0.60
x 109 /L < 0.20
Basophils x 109 /L < 0.90
Bands x 109 /L < 0.01
Metamyelocytes

Urea & Electrolytes (U&E)

Sodium mmol/L 135 - 145
Potassium mmol/L 3.2 – 4.5
Chloride mmol/L 100 - 110
Bicarbonate mmol/L 22 – 33
Calcium mmol/L 2.15 - 2.60
Phosphate mmol/L 0.7 – 1.4
Magnesium mmol/L 0.7 – 1.0
Uric Acid mmol/L 0.12 – 0.45
Urea mmol/L 3.0 – 8.0
Creatinine μmol/L 70 – 120
eGFR ml/min >90
Urea:Creatinine Ratio mmol/L 40 - 100
Lactate 0.7 - 2.5
Anion Gap mmol/L 4 - 13
Liver Function Tests (LFT)

Protein (Total)
Albumin g/L g/L 62 - 83
Globulin g/L 33 - 47
Bilirubin (Total) μmol/L 25 - 45
Bilirubin (Conjugated) μmol/L < 20 <
U/L 4.0 <50
Alkaline Phosphatase U/L <45 40 - 110
Gamma-GT U/L <40
Alanine Transaminase U/L
Aspartate Transaminase U/L
Lactate Dehydrogenase U/L
Amylase Creatine Kinase 110 -250
U/L 25 -130
< 200

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Haptoglobin g/L 0.36
–
Caeruloplasmin mg/dL 1.95 23 -
C-Reactive Protein mg/100ml 43
Erythrocyte Sedimentation Rate (ESR) mm/hr ≤ 0.8
<14 M
Fasting Lipids <12 F

Cholesterol < 5.5

mmol/L
Triglyceride mmol/L < 2.0
HDL Cholesterol mmol/L 0.9 – 1.6
LDL Cholesterol mmol/L 2.0 – 4.2
VLDL Cholesterol mmol/L calculated
Homocysteine μmol/L ≤ 13

Osmolality (plasma) mmol/kg 275 – 295

Osmolality (urine) mmol/kg 100 - 1000
Arterial Gas Parameters

PH
pCO2 7.35 -7.45
pO2 mmHg 35 - 45 75 -
Oxygen saturation mmHg 100
Bicarbonate % 94 – 98
p50 mmol/L 22 – 33
Base Excess mmHg 24 – 28
mmol/L -3.0 to +3.0
Blood Glucose

Fasting
Random
mmol/L 3.0 – 7.8
Coagulation Screen mmol/L ≥ 11.1

Prothrombin Time
APTT
INR sec 9 - 14 sec 25 - 38 0.9 – 1.3
Fibrinogen g/L 1.5 – 4.0 mg/L < 0.50 not
D-dimer done at TTH pathology lab
Fibrin Degradation Products (FDP)
Iron Studies
Serum Iron
Transferrin
Transferrin IBC
μmol/L 10 - 30
Transferrin Saturation
g/L 1.6 – 3.0
Serum Ferritin Assay
μmol/L 40 - 75
Vitamin B12
% 15 - 45
Red Cell Folate
μg/L 10 - 200
Thyroid Function Tests pmol/L > 210 >
nmol/L 630
Thyroid stimulating hormone (TSH)
Thyroxine (T4)
Triiodothyronine (T3)
mU/L 0.15 – 3.5
pmol/L 10 - 27
nmol/L 1.0 – 2.6

194
Urine Tests

Albumin:Creatinine Ratio g/mol < 2.6 M

< 3.6 F
Protein:Creatinine Ratio g/mol < 15

195
 Location of the site of a myocardial infarct

Std I aVR V1 V4

Std II aVL V2 V5

Std III aVF V3 V6

Arterial supply of these anatomical areas

Lateral LV (upper part)

Left circumflex artery (LCX)

Inferior LV
Posterior descending artery (usually from RCA)

Endocardium LV
Left coronary artery (LAD ±LCX)

Septum
Left anterior descending artery (LAD)

Lateral LV (lower part)

Diagonal branch of LAD

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 Std I aVR V1 V4

Std II aVL V2 V5

Std III aVF V3 V6

Arterial supply

Posterior LV Posterior descending artery (usually from RCA)

**********************************************************************************

Std I aVR V1 V4R

Std II aVL V2 V5

Std III aVF V3R V6

Arterial supply

Right ventricle Right coronary artery

197