Laboratory Interpretation K K

Laboratory interpretation I

Presented by Kitipatra

KalayanakoulSuthida Suwanaphan

Blood Chemistry interpretation

• Liver• Kidney• Pancreas• Electrolyte• Other …...........

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Blood chemistry

Liver Kidney

• Creatinine• BUN• Calcium•

Phosphorus• Sodium• Potassium• Chloride• Albumin•

Cholesterol

Pancreas

• Amylase• Lipase• Glucose• ALP• TLI

Electrolyte

• Sodium• Potassium• Chloride•

Magnesium

• ALT• ALP• GGT• Ammonia• Albumin• Cholesterol• Bilirubin• BUN• Bile acid

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Blood chemistry

Liver parameters

Hepatocellular leakage enzyme

Cholestatic enzyme

Liver function test

Alanine aminotransferase (ALT)

Aspartate aminotransferase(AST)

Alkaline phosphatase (ALP)

Gamma glutanyl-transferase(GGT)

Bilirubin

Bile acid

Ammonia

Urea

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Blood chemistry

Alanine Aminotransferase (ALT/SGPT)• Normal range dog >> 0-30 U/L cat >> 10-25 U/L• Enzyme located in hepatocyte cytoplasm• Leak to blood when hepatocyte cell membrane damage• Low concentration in erythrocyte/skeletal muscle

• Hepatocellular injury • Liver injury • Muscular dystrophy (dog >> slightly – moderate

cat >> slight - marked increase )• Next step : elevation > 2 times Hx hepatoxin

x-ray , ultrasound liver serum bile acid,

ALP, bilirubin• Drug effect : glucocorticoid , phenobarbital• ALT elevation indicate hepatocyte damage but dose not

reflect on overall hepatic function

Cause of high level

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Blood chemistry

Alkaline Phosphatase (ALP)• Normal range dog >> 0-90 U/L

cat >> 4-80 U/L• Membrane assosiated enzyme found in liver, bone,

colostrum, other tissue• May increase by corticosteroid induce

• Cholestasis• Drug prednisolone, phenobarbital• Osteoblast activity• Next step : disregard in young animal

evaluate hepatobiliary structure and function

review medication history assess for Cushing’s disease

Cause of high level

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Blood chemistry

Alkaline Phosphatase (ALP)

• Dog corticosteroid induction seem unique to dog dose

not differentiate source of steroid

• Cat - ALP has poor sensitivity for cholestasis except hepatic lipidosis - short serum half life (8 h) - Mild ALP elevation more clinical significant

in cat • Drug effect : corticosteroid , phenobarbital, thyroxine

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Blood chemistry

Gamma-glutamyltransferase (GGT)• Normal range dog >> 0-6 U/L

cat >> 0-4 U/L• Marker for liver disease associated with cholestasis• Membrane bound enzyme found in biliary epithelium,

renal tubular epithelium, pancreatic cell, mammary epithelial cell

• May increase by corticosteroid induce

• Cholestasis• Biliary hyperplasia• Drug corticosteroid• Next step : check ALP, bilirubin, bile acid

review medication history liver biopsy

Cause of high level

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Blood chemistry

Gamma-glutamyltransferase (GGT)

• Not clinically important

• Colostrum in most species contain high GGT• GGT can increase in 24 h after suckling

Cause of low level

GGT is more sensitivity but less specific than ALP in catsGGT is more specific but less sensitivity than ALP in

dogs

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Blood chemistry

Ammonia• Normal range dog >> 45-120 ug/dl

cat >> 30-100 ug/dl • Produce in GI and carried via portal vein to liver• Liver will change 2 ammonia to urea

• Decrease clearance decrease liver function decrease portal blood flow urea cycle abnormal

• Next step : CBC, blood chem, x-ray, U/S abdomen• Drug effect : increase >> narcotic, diuretic, high protein

diet decrease >> aminoglycosides, lactulose

Cause of high level

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Blood chemistry

Bilirubin• Normal range dog >> 0-0.3 mg/dl

cat >> 0-0.1 mg/dl• Total bilirubin• Direct (conjugated) bilirubin• Indirect (unconjugated) bilirubin

• Hemolysis next step CBC, Coomb’s test• Decrease hepatic uptake next step ALP, liver biopsy• Decrease liver function next step ALP, liver biopsy• Derease bile duct excretion next step ALP, imaging

Cause of high level

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Blood chemistry

Blood Urea Nitrogen (BUN)• Normal range dog >> 10-25 mg/dl

cat >> 5-30 mg/dl• Synthesized via hepatic urea cycle• The kidney excrete urea and freely filter by glomeruli• Serum urea concentration often parallel creatinine

concentration

• Mild-moderate >> prerenal cause : dehydration, decrease CO • Renal disease >> inflammation , degenerative, neoplasia,

congenital, toxin • Post renal cause >> urine out flow obstruction• GI hemorrhage >> increase urea production • Next step urine SG., measure UOP

Cause of high level

High dose of steroid/NSAID may cause intestinal hemorrhage >> increase BUN

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Blood chemistry

Blood Urea Nitrogen (BUN)

• Lack of hepatic urea production >> hepatic failure PSS: dehydration, decrease CO

• Increase urea excretion >> fluid, osmotic diuresis, PU/PD, DI • Next step urine SG., measure UOP, check electrolyte

Cause of Low level

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Blood chemistry

Bile acid• Normal range fasting bile acid < 5 umol/L

fasting bile acid > 20 umol/L liver disease

Postprandial sample > 25 umol/L liver disease

• Store in GB• Released as bolus into small intestine upon feeding• 95 % of bile acid are recycled

• Cholestasis next step bilirubin , ALP• Liver disease next step imaging, liver biopsy• PSS next step imaging• Sample collection : serum : 12 h fasting and 2 h postprandial

Cause of high level

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Blood chemistry

Albumin• Normal range 2.5-4.0 g/dl

young animal slightly lower • Synthesis in liver• Maintain oncotic pressure

• dehydration• Next step : assess hydration status and recheck

• Loss >> enteropathy, nephropathy, severe exudative skin lesion (burn), massive hemorrhage

• Decrease production >> severe chronic liver disease• Next step : PE intestinal, renal, liver function

assess HCT, TP, liver enz, renal function UPC ratio, fecal floatation, fecal occult

blood

Cause of high level

Cause of low level

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Blood chemistry

Cholesterol • Normal range dog >> 112-328 mg/dl

cat >> 82-218 mg/dl• Lipid that found only in tissue• Synthesized by liver/ absorbed in intestines• Major component of cell membrane / precursor of steroid

hormone• Filtered by glomerulus and reabsorption by renal tubule

• Primary hyperlipidemia : idiopathic in schnauzer• Secondary hyperlipidemia : post prandial, hypothyroidism , DM,

liver disease, cushing’s dz, pancreatitis, nephrotic syndrome

• Next step Assess for cause of secondary hyperlipidemia If no cause identified >> pimary hyperlipidemia

• Drug effect exogenous corticosteroid

Cause of high level

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Blood chemistry

Cholesterol

• Chronic liver disease• Starvation • Next step evaluate for chronic liver disease

Cause of low level

Fast 10-12 hour before check serum cholesterol

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Blood chemistry

Liver disease Disease ALT ALP GGT BUN

NH3 bilirubin

Albumin

Chronic active hepatitis

N/ N N/ N/

Hepatic necrosis

N N N/ N

Cirrhosis N/ N/ N/ N/ N N/ N/

Hepatic lipidosis

N/ N N N/ N

Cholangio-hepaitis

N/ N N N

Steroid hepatopathy

N N N N

Bile duct obstruction

N N N

PSS N/ N/ N/ N/ N/ N/

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Blood chemistry

• ALT• ALP• GGT• Ammonia• Albumin•

Cholesterol• Bilirubin• BUN• Bile acid

Liver KidneyPancreas

• Amylase• Lipase• ALP• Glucose• TLI

Electrolyte

• Sodium• Potassium• Chloride• Magnesium

• Creatinine• BUN• Calcium• Phosphorus• Sodium• Potassium• Chloride• Albumin• Cholesterol

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Blood chemistry

Creatinine • Normal range 0-1.5 mg/dl• Waste product result from degradation of muscle creatinine• Freely filtered by glomerulus • Not reabsorption by renal tubule

• Decrease GFR• Animal with greater muscle mass (grayhound)• Next step check BUN, urine SG

• Muscle loss• Next step evaluate cause of muscle loss

Cause of high level

Cause of low level

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Blood chemistry

Creatinine

Stage Plasma creatinine (mg/dl)

comment

Dog cat< 1.4 < 1.6 Risk of CKD

1 < 1.4 < 1.6 Non-azotemic

2 1.4 – 2.0 1.6 – 2.8 Mild renal azotemia

3 2.1 – 5.0 2.9 – 5.0 Moderate renal azotemia

4 > 5.0 > 5.0 Severe renal azotemia

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Blood chemistry

Blood Urea Nitrogen (BUN)• Normal range dog >> 10-25 mg/dl

cat >> 5-30 mg/dl• Synthesized via hepatic urea cycle• The kidney excrete urea and freely filter by glomeruli• Serum urea concentration often parallel creatinine

concentration

• Mild-moderate >> prerenal cause : dehydration, decrease CO • Renal disease >> inflammation , degenerative, neoplasia,

congenital, toxin • Post renal cause >> urine out flow obstruction• GI hemorrhage >> increase urea production • Next step urine SG., measure UOP

Cause of high level

High dose of steroid/NSAID may cause intestinal hemorrhage >> increase BUN

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Blood chemistry

Blood Urea Nitrogen (BUN)

• Lack of hepatic urea production >> hepatic failurem PSS: dehydration, decrease CO

• Increase urea excretion >> fluid, osmotic diuresis, PU/PD, DI• • Next step urine SG., measure UOP, check electrolyte

Cause of Low level

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Blood chemistryAzothemia

Increase only BUN

High protein diet

GI hemorrhagedehydration

Increase BUN+creatinine

Present of dehydration, hypovolumia

Yes No

Prerenal azotemia

History of trauma History of PU/PD

Image abdomenRenal calculiRenal mass

Fluid in abdomen

History of dysuria/

Stranguria

YesNo

CRFNo

YesSize of UB

Small Large

Urine catheter

Postrenal azotemia

ARFRenal

azotemia

Check USG

Obstruction

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Blood chemistry

Calcium (Ca)

• Normal range Total Ca >> 8-11.5 mg/dl Ionized Ca >> 4.5-6 mg/dl

• Regulated by parathyroid hormone (PTH) , calcitriol• 98 % reabsorbed by renal tubular

• Low ionized Ca stimulate PTH production - mobilzing Ca from bone- increase renal tubular resorption- stimulating calcitriol synthesis

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Blood chemistry

Calcium (Ca)

• Hypercalcemia of malignancy :- hypoadrenocorticism- primary hyperparathyroidism- osteolysis- hypervitaminosis D- renal failure- excess supplementation

• Next step : evaluate for neoplasm, exposure to oral vit D, measure serum phosphorus, parathyroid hormone

Cause of high level

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Blood chemistry

Calcium (Ca)

• Hypoalbuminemia• Renal failure• Eclamsia• Hypoparathyroidism• EPI• Ethylene glycol intoxication• Malabsorption syndrome• Acute lysis tumor syndrome • hypomagnesemia• Next step : measure serum albumin, evaluate for renal failure,

gastrointestinal disease , measure parathyroid hormone, Mg

Cause of low level

Acidosis can increase ionized serum Ca; Alkalosis decrease it

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Blood chemistry

Phosphorus (P) • Normal range dog >> 3.2-1.8 mg/dl

cat >> 3.2-6.5 mg/dl

• Decrease urinary excretion >> decrease GFR• Hypoparathyroidism• Increase intesinal absorption• Myopathies• Osteolytic bone lesion• Next step rule out artifact >> repeat

evaluate kidney function, PTH, Ca , x-ray• Drug effect : phosphate enema

intravenous supplement furosemide, hydrochlorothiazide

Cause of high level

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Blood chemistry

Phosphorus (P)

• Increase renal excretion >> Fanconi’s syndrome• Prolong anorexia• malabsorption• Hypovitaminosis D• Humoral hypercalcemia of malignancy• hyperinsulinism• Next step : check CBC, blood chemistry, urinalysis• Drug effect : antacid

diuretic insulin, biarbonate anticonvulsant

Cause of low level

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Blood chemistry

Albumin• Normal range 2.5-4.0 g/dl

young animal slightly lower • Synthesis in liver• Maintain oncotic pressure

• dehydration• Next step : assess hydration status and recheck

• Loss >> enteropathy, nephropathy, severe exudative skin lesion (burn), massive hemorrhage

• Decrease production >> severe chronic liver disease• Next step : PE intestinal, renal, liver function

assess HCT, TP, liver enzyme, renal function

UPC ratio, fecal floatation, fecal occult blood

Cause of high level

Cause of low level

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Blood chemistry

Cholesterol • Normal range dog >> 112-328 mg/dl

cat >> 82-218 mg/dl• Lipid that found only in tissue• Synthesized by liver/ absorbed in intestines• Major component of cell membrane / precursor of steroid

hormone• Filtered by glomerulus anf reabsorption by renal tubule

• Primary hyperlipidemia : idiopathic in schnauzer• Secondary hyperlipidemia : post prandial, hypothyroidism , DM,

liver disease, cushing’s dz, pancreatitis, nephrotic syndrome

• Next step Assess for cause of secondary hyperlipidemia If no cause identified >> pimary hyperlipidemia

• Drug effect exogenous corticosteroid

Cause of high level

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Blood chemistry

Cholesterol

• Chronic liver disease• Starvation • Next step evaluate for chronic liver disease• Drug effect lipid lowering diet, bile acid sequestrant, hepatic

hydroxymethylglutaryl coenzyme A reductase inhibitor

Cause of low level

Fast 10-12 hour before check serum cholesterol

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Blood chemistry

Liver Kidney


Phosphorus• Sodium• Potassium• Chloride• Albumin•

Cholesterol

Pancreas


Cholesterol• Bilirubin• BUN• Bile acid

Electrolyte• Sodium• Potassium• Chloride•

Magnesium


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Blood chemistry

Amylase• Normal range dog >> 371-1503 U/L

cat >> 530-1660 U/L • High concentration in pancreas, intestine and liver• Ca is required cofactor• Eliminate via urinary tract

• Pancreatitis in dog• Vomiting• Decrease GFR (increase less than three times)• Next step : CBC, blood chemistry, abdominal U/S• Cat with pancreatitis often do not elevated serum

amylase

Cause of high level

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Blood chemistry

Lipase • Normal range dog >> 100- 750 IU/L

cat >> 10-195 IU/L• Present in pancreas• Hydrolyzes triglyceride to fatty acid and glycerol

• Pancreatitis• Renal failure• Azotemia• Hepatic disease• Duodenal obstruction• Next step evaluate pancreatitis >> U/S abdomen, renal

disease• Drug effect : increase >> Dexamethasone, PrednisoloneLipase measured by enzymatic activity is not reliable indicator of pancreatitis in cat (Pancreatic lipase immunoreactivity)

Cause of high level

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Blood chemistry

Lipase (con.)

• Exocrine pancreatic insufficiency• Next step check serum trypsin-like immunoreactivity (TLI)

Cause of low level

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Blood chemistry

Glucose • Normal range dog>> 60-125 mg/dl

cat >> 70-150 mg/dl

• Diabetes mellitus• Cushing• Stress• Hyperthyroid• pancreatitis• Next step urine glucose, ketone, serum fructosamine

• Long term starvation• Insulin overdose• Paraneoplastic syndrome• Chronic liver disease• Next step check serum protein, T4

Cause of high level

Cause of low level

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Blood chemistry

Trypsin-like Immunoreactivity (TLI) • Normal range dog>> 5-35 ug/L

cat >> 12-82 ug/L• Trypsinogen is produce by pancreatic acinar• Low concentration in blood in normal animals

• Pancreatitis (TLI > 50 ug/L in dog, > 100 ug/L in cat)• Next step not usually used for diagnosis of pancreatitis

clinical sign, image, increase amylase/lipase

• EPI (dog < 2.5 ug/L, cat <8 ug/L)• Severe chronic persistent pancreatitis

Cause of high level

Cause of low level

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Blood chemistry

Liver Kidney


Phosphorus• Sodium• Potassium • Chloride• Albumin•

Cholesterol

Pancreas


Cholesterol• Bilirubin• BUN• Bile acid Electrolyte


• Sodium• Potassium• Chloride• Magnesium

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Blood chemistry

Sodium (Na)• Normal range dog >> 140-150 mEq/L

cat >> 150-160 mEq/L• Major extracellular cation• Serum concentration is net of oral intake, excretion, water shift• Concentration regulated by GFR and renal tubular reabsorption

• Hypovolemia : hypovolemia fluid loss >> vomiting, diarrhea, pancreatitis, peritonitis, renal failure, postobstructive diuresis

• Normovolemia : pure water loss >> DI, high temperature, brainstem disease

• Hypervolemia : Na gain (uncommon) >> hypertonic fluid, hyperaldersteronism

• Next step evaluate hydration status, rule out listed disease• Drug effect >> increase >> osmotic diuresis, furosemide, corticosteroid

Cause of high level

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Blood chemistry

Sodium (Na)

• High osmolarity >> hyperglycemia, manital administration• Low osmolarity

- Hypovolemia >> vomiting, diarrhea, pancreatitis, peritonitis, pleural effusion, uroabdomen, hypoadrenocorticism, diuretic, ketonuria, Na-wasting nephropathy- Normovolemia >> hypotonic fluid, inappropiate ADH secretion- Hypervolemia >> heart failure, severe hepatopathy, nephrotic syndrome

• Next step evaluate hydration status rule out listed disease measure plasma osmolarity and frational Na

excretion• Drug effect >> decrease >> furosemide, prolong diuretic drug

Cause of low level

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Blood chemistry

Potassium (K) • Normal range 3.5-5.5 mEq/L• Major intracellular cation• Important in cardiac and neuromuscular membrane potential• Normal >> shift K from ECF to ICF >> hyperkalemia is

uncommon• Influence by acid-base status

Acid >> ECF shift and hyperkalemia

• Decrease renal excretion >> renal failure, urinary tract obstruction/rupture

• DKA• Metabolic acidosis• Gastrointestinal disease• Next step check CBC , x-ray, U/S, Blood gas

evaluation for drug that cause hyperkalemia• Drug effect : ACE inhibitor, spironolactone, oversupplement K

Cause of high level

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Blood chemistry

Potassium (K)

• Increase loss : vomit, diarrhea• Chronic renal failure• Postobstructive diuresis• hyperaldosteroneism• Inappropiate fluid therapy

• Next step check CBC , x-ray, U/S, blood gas

• Drug effect : loop diuretic, thiazide diuretic, amphotericin B, penicillin, administration of K free fluid

Cause of low level

Important to check blood gas in hypokalemia and hyperkalemia animal

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Blood chemistry

Chloride (Cl)• Normal range dog >> 105-115 mEq/L

cat >> 115-125 mEq/L• Major extracellular anion• Regulate acid-base balance• Filtered by glomerulus and reabsorption by renal tubule

• With proportional Na increase : hypernatremia• Without proportional Na increase :

- hyperchloremic acidosis (GI/renal loss)- compensation for chronic respiratory alkalosis

• Next step evaluate acid-base, calculate proportional change relative to Na

Cause of high level

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Blood chemistry

Chloride (Cl)

• With proportional Na decrease : hyponatremia• Without proportional Na decrease :

- hypochloremic alkalosis (GI loss)- compensation for chronic respiratory acidosis

• Next step evaluate acid-base, calculate proportional change relative to Na

• Drug effect : decrease >> thiazide, loop diuretic, NaHCO3

increase >> KCl, saline administration, acetazolamide, spinorolactone

Cause of low level

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Blood chemistry

Magnesium • Normal range 1.5-2.7 mg/dl

• Decrease urinary excretion >> decrease GFR• Excess oral administration (uncommon)• Next step evaluate renal function

oral/paenteral supplement• Drug effect : loop and osmotic diuresis >> increase renal excretion

Insulin/bicarbonate >> intracellular shifing

Cause of high level

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Blood chemistry

Magnesium

• Hypoproteinemia• Excess urinary excretion >> diuresis• Inadequate gastrointestinal absorption >> chronic diarrhea,

malabsorbtion• Shift from ECF to ICF >> Tx DKA• DM, hyperparathyroidism, hyperthyroidism• Next step : check serum albumin

evaluate renal/GI disease• Drug effect : Mg containing laxative/ antacid

Cause of low level

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Blood chemistry

Miscellaneous

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Blood chemistry

Lactate • Normal range 1.8-22.5 mg/dl

• Metabolic end product of anaerobic glycolysis• Increase production energy production under anaerobic condition lactic acidosis • Liver and kidney are the primary consumer

• Hypoxia : severe exercise, seizure, shock, cardiac disease• Non-hypoxia : GDV, DM, liver failure, renal failure, neoplastic babesiosis• Next step evaluate underlying cause• Drug effect : increase >> phenobarbital, epinephrine• Poor prognosis

Cause of high level

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Blood chemistry

Globulins • Normal range dog>> 2-4 g/dl

cat >> 2.5-5 g/dl

• Chronic inflammation• Hepatic disease• FIP• Immune-mediated disease• Lymphosarcoma• E.canis• Next step evaluate A:G ratio, protein electrophoresis

Cause of high level

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Blood chemistry

Globulins

• Normal albumin level immunodeficiency hepatic insufficiency

• Hypoalbuminemia hemorrhage protein loss malnutrition hepatic insufficiency

• Next step evaluate A:G ratio, evaluate hemorrhage Assess for renal/GI protein loss, hepatic failure,

malnutrition

Cause of low level

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Blood chemistry

Fructosamine • Normal range < 200 umol/dl• Assessing the average serum glucose over preceding 2-3

weeks• Differentiate stress-induce hyperglycemia

• Persistent hyperglycmia• Next step Hx, PE, serum glucose, urine glucose

• Hypopreteinemia• Hypothyroid cat• Next step check serum protein, T4

Cause of high level

Cause of low level

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Blood chemistry

Glucose • Normal range dog>> 60-125 mg/dl

cat >> 70-150 mg/dl

• Diabetes mellitus• Cushing• Stress• Hyperthyroid• pancreatitis• Next step urine glucose, ketone, serum fructosamine

• Long term starvation• Insulin overdose• Paraneoplastic syndrome• Chronic liver disease• Next step check serum protein, T4

Cause of high level

Cause of low level

Coagulation Profile

• platelet• vWf• fibrinogen• ACT, APTT, PT• FDPs …...........

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Coagulation Profile

Bleeding/Coagulopathies

Hx/PE

HematemesisMelenaHematuriaEpistaxisPetechiae/ecchymosis

Mucosal hemorrhageHematemesisHematuriaHematomaHemorrhage in body

cavityRodenticide / Drug history

Primary hemostatis

Secondary hemostatis

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Coagulation Profile

Tests for hemostasis

• Platelet number• Platelet function• vWf• Bleeding time

• TT• PT• APTT• ACT• Fibrinogen

Primary hemostatis


Tertiary hemostatis• FDPs

• D-dimer

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Coagulation Profile Tests for Primary hemostatis

• evaluated by platelet counts

• anticoagulant : EDTA

• determined in 2 ways :

1) Estimate from blood smear- 100x oil immersion objective- monolayer of smear- average 10-15 platelets/field

2) Quantitative counts- hemocytometer- electronic cell counter

Platelet number

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• Thrombopathies = disorder of platelet function

• Tests :

1) measure of platelet adhesion

2) measure of platelet aggregation

3) measure of platelet release reaction

• only available at specialized vet lab

Platelet function

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• a large glycoprotein, composed of series of protein polymer

• Tests :

1) quantitative measurement- rocket immunoelectrophoresis- ELISA

: using anti-vWf antibody

2) qualitative measurement- evaluation of multimeric structure of vWf

3) functional measurement- in vivo using BMBT- in vitro using platelet aggregation collagen

binding assay

vWf

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• a useful in vivo test to evaluate 1˚ hemostasis

• in vivo, prescreening test for vWD, esp. Dobermans

• Tests :1) Buccal mucosal bleeding time (BMBT)

- small animal

2) Lip bleeding time

- large animal

Bleeding time

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Coagulation Profile



• PT• APTT• ACT• Fibrinogen

Primary hemostatis


Tertiary hemostatis

• FDPs• D-dimer

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Coagulation Profile

Activated cogulation time (ACT)

• Normal range : <140 sec• Time interval from contact of blood + diatomaceous earth

pellet a blood clot

• Intrinsic / common pathway factors• Severe thrombocytopenia• Confirm with APTT, platelet counts

• Drug effect >> Heparin or aspirin therapy

Cause of high level

Tests for Secondary hemostatis

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Coagulation Profile

Activated Partial thromboplastin time (APTT)

• Normal range : 8-18 sec• Screening test for intrinsic and common pathway

(Every clotting factors except factor VII, XIII)

• Liver disease (decrease factor production)• Vitamin K inactivation • Vitamin K absorption (biliary obstruction)• DIC (increase factor consumption)• Factor dilution (massive blood loss with crystalloid

replacement)• Drug effect >> Heparin or aspirin therapy

Cause of high level

APTT before PT with heparin therapy …but not with rodenticide toxic or coagulopathy of liver

disease !


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Coagulation Profile

Prothrombin time (PT)

• Normal range : dog >> 5-8 sec. : cat >> 7-11 sec.

• Screening test for extrinsic and common pathway

• Liver disease (decrease factor production)• Vitamin K deficiency • DIC (increase factor consumption)• Anticoagulant intoxication• Present of fibrin degradation product• Rule out aquired diseases / DIC• Drug effect >> Heparin

Cause of high level

Rodenticide toxicosis or liver disease tend to PT before APTT (factor VII has short half life)


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Coagulation Profile

Fibrinogen

• Normal range : 150-300 mg/dl• Glycoprotein important in hemostasis• Made in liver, production by inflammation / tissue damage

• Dehydration (hemoconcentration)• Increase production by liver (inflammation/tissue damage)• Next step : look for source of inflammation

CBC, blood chemistry profile

• Increase consumption : DIC, increase fibrinogenolysis, decrease hepatic fibrinogen synthesis

• Next step : coagulation profiles assess DIC blood chem. evaluate hepatic

parameters serum bile acid evaluate hepatobiliary

function

Cause of high level

Cause of low level


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Coagulation Profile



• PT• aPTT• ACT• Fibrinogen

Primary hemostatis Secondary hemostatis

Tertiary hemostatis

• FDPs• D-dimer

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Coagulation Profile

Fibrin or Fibrin degradation products (FDPs)

• Normal range dog >> 0-10 ug/ml cat >> 0-8 ug/ml

• Protein fragment of fibrin or fibrinogen that cleage by plasmin

• FDPs are potent inhibitor of coagulation• FDPs interfere with platelet aggregation• Eliminate by liver and kidney

• Increase fibrinolysis >> internal hemorrhage, DIC

• Decrease FDPs clearance >> liver disease, kidney disease

• Next step : CBC, blood chem. profiles Urinalysis Coagulation profiles

Cause of high level

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Coagulation Profile

Primary hemostatis

Platelet counts

thrombocytopenia

normal

BMBT

Prolonged

normalPlatelet

dysfunction

Vessel Defect ? Vascular disease

Von willebrand’s diseaseDrug ?UremiaHepatic diseaseSystemic disease

CNT disorderCushing’s diseaseDrug ?DMSystemic infection

1

23

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Coagulation Profile

Platelet counts, PT,APTT

abnormal

normal

BMBT

Normal platelet

normal

FDPs PT

DIC

RodenticideVit K

deficiency

Secondary hemostatic

platelet

increase

APTT

Early DICthrombocytopeni

a

APTT,PT

Factor VII deficiency

vWDFactor VIII, IX, XI. XII deficiency

RodenticideHepatic disease DIC

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Diagnostic tests

vWD

Vit K def.

Peracute DIC

Acute DIC

Chronic DIC

Platelet

Liver disease

Platelet count

N N to N to N to N

Bleeding time

- - -

ACT

N N

N to NAPTT

PT

Fibrinogen N N N or or N

FDPs N N to N to N to N Sl.

Blood morphology

N N Schistocytosis N N

Blood gas interpretation

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i-Stat

EC4 (350) G3 (280) CG4 (400) EG7 (500)Na pH pH pH

K PCO2 PCO2 PCO2

HCT PO2 PO2 PO2

Hb TCO2 TCO2 TCO2

glucose HCO3 HCO3 HCO3

BE BE BE

SO2 SO2 SO2

lactate Na

K

Ionize Ca

HCT

Hb

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• Acid – base disturbance - Respiratory acidosis/alkalosis >> volatile acid- Metabolic acidosis/alkalosis >> fixed acid

• Adaptive response /secondary response

• Simple/ Mixed• Simple >> primary cause and then compensate by

adaptive response

(Compensate do not Overcorrection !!!)• Mixed >> 2 problems

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• Normal range 7.35-7.45 (7.4)• Does the pH normal ?• Alkalosis pH > 7.4• Acidosis pH < 7.4

• PCO2 for respiratory system

normal range 35-40 (37) PCO2 is acid increase = acidosis

decrease = alkalosis• HCO3

- for metabolic system

normal range 18-24 (21) HCO3

- is base increase = alkalosis

decrease = acidosis• Compare to pH , which system is primary disturbance ?

pH

What system is the primary disturbance ?

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• Dose the body compensate ?

• The primary disturbance decrease but the secondary disturbance increase mixed disturbance

• The primary disturbance decrease and the secondary disturbance decrease check compensatory response

If in range (+/- 2) simple disturbanceIf not in range mixed disturbance

Is it a mixed or simple disturbance?

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Compensatory response from primary acid-base disorder

Disorder Primary change

Conpensatory change

Metabolic acidosis [HCO3-]

PCO2 0.7 mmHg in every

1 mEq/L of [HCO3-]

Metabolic alkalosis [HCO3-]

PCO2 0.7 mmHg in every

1 mEq/L of [HCO3-]

Acute respiratory acidosis

PCO2 [HCO3-] 1.5 mEq/L in

every 10 mmHg of PCO2

Chronic respiratory acidosis



Acute respiratory alkalosis



Chronic respiratory alkalosis



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Anion gap• Electroneutrality cation = anion

• There are unmeasured anion more than unmeasured cation anion gap

• Anion gap = [Na+] + [K+] – [Cl-] – [HCO3-]

Cations Anions

Na+

K+

Other

Cl-

HCO3-

Other Anion gap

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Metabolic Acidosis

• We can differentiate the group of metabolic acidosis from anion gap into 2 group

1. Metabolic acidosis with increase anion gap2. Metabolic acidosis with normal anion gap

Na+

K+

Cl-

HCO3-

Na+

K+

Cl-

HCO3-

Na+

K+

Cl-

HCO3-

Normal pH

12

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Metabolic Acidosis

Metabolic acidosis with increase anion gap

• Add fixed acid in the extracellular compartment so the cell use HCO3

- to buffer it• “Acid addition syndrome”

Diabetic ketoacidosisLactic acidosisRenal failureToxin ingestion ex. Ethylene glycol, methanol

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Metabolic Acidosis

Metabolic acidosis with normal anion gap

• Loss of HCO3- from the kidney or GI tract

• decrease [HCO3- ] in blood and GFR

• Na reabsorption have to exchange Na with anion (Cl-/ HCO3

- ) to make it neutral

• When [HCO3- ] decrease, the cell have to exchange with

Cl-

• increase [Cl- ] change anion gap• “Bicarbonate loss syndrome”

Diarrheacarbonic anhydrase inhibitor ex. acetazolamideRenal tubular acidosis

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Metabolic Acidosis

• Severe metabolic acidosis may cause- arrhythmia- vasodilate / vasoconstrict- hyperkalemia

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Metabolic Alkalosis

• Vomiting - loss of Cl- from vomit- decrease [Cl- ] in circulation and GFR- Na reabsorption have to exchange with HCO3

-

Alkalosis

• Metabolic alkalosis may be cause hypokalemia

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Respiratory Acidosis

• Increase PCO2

• Cause increase production or decrease excretion• Main cause alveolar hypoventilation (decrease

excretion) hypoxia• Disease

- decrease RR brain Anesthetic drugs- increase RR airway obstruction

pleural disease lung collapse

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Respiratory Alkalosis

• decrease PCO2

• Cause hypoxia• Disease

- Pleural disease- Anemia- Oxidized hemoglobin - Pain- Hyperthermia

• Diagnosis with PO2 to rule out compensatory response to hypoxia

#


What is your interpetation?

- pH 7.182

- pCO2 31.5 mmHg

- pO2 29.2 mmHg

- HCO3 11.5

- Na 133

- K 6.37

- Cl 77

Metabolic Acidosis

Metabolic acidosis [HCO3-]

PCO2 0.7 mmHg in

every 1 mEq/L of [HCO3-]

HCO3 21-11.5 = 9.5

PCO2 9.5 x 0.7 = 6.65 1

PCO2 (expected) = 37-6.65 = 30.35

Metabolic acidosis compensate with respiratory alkalosis

#



- pH 7.547

- pCO2 26.2 mmHg

- pO2 45.8 mmHg

- HCO3 22.2

- Na 136

- K 2.03

- Cl 131

Respiratory Alkalosis

Acute respiratory alkalosis



PCO2 37-26.2 = 10.8

HCO3 2.5 x 10.8 = 2.7 10

HCO3 (expected) = 21-2.7 = 18.3

Mixed Respiratory Alkalosis with metabolic acidosis

#



- pH 6.963

- pCO2 58.1 mmHg

- pO2 47.0 mmHg

- HCO3 12.9

- Na 128

- K 2.90

- Cl 106

Respiratory Acidosis

Acute respiratory acidosis



PCO2 58.1-37 = 21.1

HCO3 21.1 x 1.5 = 3.16 10

HCO3 (expected) = 21+3.16 = 24.16

Mixed Respiratory acidosis with Metabolic alkalosis

Urinalysis

• Physical•

Chemical

• Sediment

…...........

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Urinalysis

Urinalysis

Urine sample

Physical properties

Chemical properties

Centrifuge

ColorTurbidityVolumeSmellUrine specific gravity

Chemical drip stick

Urine sediment

Discard the supernatant

Stained sediment

Drop at slide

http://www.fetchdog.com/Shop?DSP=30201&IID=AR000010085&imagesequence=0

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Urinalysis

Physical properties >> Color

• Yellow

• Red Hematuria >> after centrifuge urine will change to yellow

Hemoglobinuria >> intravascular hemolysis

• Dark yellow concentrate >> after shake the bubble is white bilirubin >> after shake the bubble is yellow

• Blue-green pseudomonas infection

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Urinalysis

Physical properties >> Turbidity

• Clear and transparent

• Cloudy increase in cell, mucus, crystal or microorganism

centrifuge

check urine sediment

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Urinalysis

Physical properties >> Smell

• Ammonia urine infection with bacteria that produce urease

• Ketone Diabetic ketone acidosis

• Bad smell protein degradation necrosis

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Urinalysis

Physical properties >> Volume

• 1-2 ml/kg/h or 20 ml/kg/d

• Increase volume >> Urine SG. decrease

• Decrease volume >> Urine SG. increase

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Urinalysis

Physical properties >> Specific Gravity

• Normal range dog 1.001-1.075 cat 1.001-1.080

• Total solute concentration compare with water

• Hyposthenuric urine urine SG. 1.001-1.007• Isosthenuric urine urine SG. 1.008-1.012• Hypersthenuric urine urine SG. > 1.012

• If … dehydrated or hypovolumia Dog > 1.030Cat > 1.035If < inappropiate diluting urine

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Urinalysis


• Azotemia >> Urine SG. > 1.030 or 1.035 Prerenal cause

Urine SG. < 1.030 or 1.035 Renal cause

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Urinalysis


PU/PD + dehydration

< 1.008 1.008-1.030

> 1.030

Active diluting urine

Inappropriate diluting urine

Concentrate urine

Diabetic incipidusPsychogenic polydipsia

Renal diseaseHypokalemiaHyponatremia

Diabetic mellitus

Cushing disease, Liver disease, PyometraHyperthyroidism, Hypercalcemia

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Urinalysis

Chemical properties >> urine pH

• Normal range 5-7.5• Food

Carnivore aciduria Herbivore alkalinuria

• MetabolismMetabolic acidosis / Respiratory acidosis aciduriaMetabolic alkalosis / Respiratory alkalosis alkalinuria

• Infection alkalinuria >> bacteria produce urease enzyme• Hematuria / Hemoglobinuria alkalinuria >> blood pH = 7.4

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Urinalysis

Chemical properties >> Protein

• Most = globulin• 20 mg% < Protein > 1 g% • Concentrate urine >> protein +1• Urine SG = 1.060 >> protein +2

• False positive - alkalinuria- contaminated with quaternary ammonium compound

• False negative- dilute urine

#

Urinalysis


• Urine protein creatinine ratio (UPC ratio) • Normal range < 0.5• Indication

- proteinuria- hypoalbuminemia

• Diagnosis >> protein lossing nephropathies

• Charateristic of protein status Dogs CatsNonproteinuria < 0.2 < 0.2Borderline proteinuria 0.2-0.5 0.2-0.4Proteinuria > 0.5 > 0.4Glomerulus or tubular proteinuria 0.5-2.0 0.4-1.0Glomerular proteinuria > 2.0 > 1.0

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Urinalysis


• Proteinuria >> Post glomerular vessel contraction (Functional proteinuria)

Fever Congestive heart failure

Pre- renal >> Bence jones protein Intravascular hemolysis Hemoglobinuria Muscle damage Myoglobinuria

Renal >> increase permeability >> Glomerulonephritis Amyloidosis

>> cannot reabsorption >> Fanconi’s syndrome

Post- renal >> urinary tract inflammation (RBC & WBC↑)

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Urinalysis

Chemical properties >> Glucose

• Do not found glucose in urine• If found glucose in urine blood glucose > renal plasma

threshold• Renal plasma threshold dog 180 mg%

cat 270 mg%

• False positive - contaminated with hydrogen peroxide, chlorine

• False negative- Vitamin C

If there are bacteria in urine, Glucose in urine will decreaseIf urine is cool, It will not develop color on dipstick

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Urinalysis

Chemical properties >> Glucose

• Glucosuria >> Diabetes Mellitus

Stress/excite cat !!! Fluid D5W, … Fanconi’s syndrome >> glucosuria but…

blood glucose is normal

Fanconi’s syndrome and renal glucosuria> glucosuria but… blood glucose is

normal

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Urinalysis

Chemical properties >> Ketone

• Ketone >> acetone, acetoacetic acid, ß-hydroxybutyric acid

• Dipstick cannot check ß-hydroxybutyric acid

• False positive rare

• False negative evaporation, bacteria

• Ketonuria >> Abnormal lipid metabolism Diabetic ketoacidosis (dog) Fever

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Urinalysis

Chemical properties >> RBC/Hemoglobin

• Hemoglobin > RBC

• False positive- contaminate with iodide, Bromide

• False negative- Vitamin C

• Hematuria >> Vessel Urinary tract

• Hemoglobinuria >> Blood parasite Splenic torsion Immune mediated disease

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Urinalysis

Chemical properties >> Bilirubin

• Bilirubin > 0.5 mg%• Low bilirubin renal threshold in male dogs may be found

bilirubin in urine• In cat , If you found bilirubin in urine abnormal• Found bilirubin in urine before plasma bilirubin• False positive

- Chlorpromazine• False negative

- Vitamin C, UTI

• Bilirubinuria >> Liver disease Hemolysis Fever Stavation

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Urinalysis

Chemical properties >> Urobilinogen

• Bilirubin intestinal bacteria urobilinogen• Eliminate by urine

aciduria >> decrease elimination alkalinuria >> increase elimination increase

urobilinogen• Check immediately because it can oxidize

• Urobilinogenuria >> Not found >> bile duct obstruction

Abnormal bile productionProduce >>Liver disease

Hemolysis Constipation Enteritis Intestinal obstruction

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Urinalysis

Chemical properties >> Leukocyte

• Use in human• Not useful in animal

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Urinalysis

Urine sediment >> Cells

• Red blood cell

• Method- void >> 0-8 cells/HPF- catherization >> 0-5 cells/HPF- cystotomy >> 0-3 cells/HPF

• Cause- Calculi- Trauma- UTI- Prostate gland- coagglulopathy- Estrus

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Urinalysis

Urine sediment >> Cells

• White blood cell• most neutrophil• Method

- void >> 0-8 cells/HPF- catherization >> 0-5 cells/HPF- cystotomy >> 0-3 cells/HPF

• Cause- UTI (bacteria, fungal, yeast)- Contaminated from vagina/prepuce- Calculi- Tumor

If you found Bacteria with WBC >>urine C/S

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Urinalysis

Urine sediment >> Epithelial Cell

• Squamous cell• large cell with small nucleus• Distal urethra / Vagina• Can found little• Female dog in estrus can found more

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Urinalysis

Urine sediment >> Epithelial Cell

• Transitional epithelium cell• small round cell with round nucleus• Proximal urethra, bladder, ureter and

renal pelvis• 1 cell or sheets• Caudate cell >> renal pelvis• Cause

- UTI- Tumor

• Transitional cell has many nucleus or diviation >> severe infectiontransitional cell carcinoma

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Urinalysis

Urine sediment >> Cast

• Normal hyaline cast < 2 casts/LPFgranular cast < 1 casts/LPF

• Hyaline casts• homogenous and transparent• Mucoprotein• Not significant• found in proteinuria

concentrate urine aciduria

• Dilute urine and alkalinuria can degrade hyaline cast

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Urinalysis


• Red blood cell casts• Red blood cell in cast• Bleeding / inflammation / trauma at kidney• Acute glomerulonephritis

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Urinalysis


• White blood cell casts• White blood cell in cast• Inflammation at kidney• Cause

- Acute pyelonephritis- Acute tubular necrosis

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Urinalysis


• Epithelial casts• renal tubular epithelium• Difficult to differentiate from WBC cast >> cellular cast• Cause

- toxin- kidney infraction- pyelonephritis

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Urinalysis


• Granular casts• mucoprotein , plasma protein and tubular cell• Most common• Coarse granular cast• Fine granular cast• Cause >> acute tubular necrosis

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Urinalysis


• Waxy casts• wide cast without granule, transparent , homogeneous• Degradation of granular cast• Cause >> chronic kidney disease

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Urinalysis


• Fatty casts• round fat droplet in cast• Common in cat >> tubular epithelium cell in cat have lipid• Cause >> DM, hyperlipidemia, nephrotic syndrome

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Urinalysis

Urine sediment >> Organism

• Normal no organism in urine• Bacteria rod / cocci• Void/catherization contaminate with bacteria at distal urethra• Urine culture and sensitivity

cystotomy• If you do not find bacteria in urine sediment , It doesn’t mean

that dog does not have UTI• bacteria rod 10,000 cells

cocci 100,000 cells

Found in urine sediment

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Urinalysis

Urine sediment >> Crystals

• Basic urine >> Struvite, Amorphus phosphate, Calcium carbonate,

Ammonium urate

• Acid urine >> Urates, Cystine, Oxalate, Hippurate

• Calcium oxalate >> acute renal failure esp. ethyleneglycol toxic

• Liver not function >> ammonium biurate, leucine, tyrosine

• Concentrate urine >> bilirubin crystal

• Cystalluria is not relate to calculi•

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Urinalysis

Urine sediment >> Crystals • Basic urine Struvite cystal Amorphus

phosphate

Ammonium biurate Calcium carbonate

•

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Urinalysis

Urine sediment >> Crystals • Acid urine Calcium Oxalate Urate

Cysteine

•

• Calcium oxalate >> acute renal failure esp. ethyleneglycol toxic

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Urinalysis

Urine sediment >> Crystals

• Bilirubin crystal >> concentrate urine/hyperbilirubinemia

• Liver not function >> ammonium biurate, leucine, tyrosine Tyrosine Ammonium biurate Leucine

•

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Urinalysis

What do you see in urine sediment ?

WBC

Rod bacteria

Squamous cell

Transitional cell

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Urinalysis

What do you see in urine sediment ?

RBC

Struvite crystal

Thank you

Documents

Laboratory Interpretation K K