Ebook Laboratory medicine - The diagnosis of disease in the clinical laboratory (2/E): Part 1

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Part 1 book "Laboratory medicine - The diagnosis of disease in the clinical laboratory" includes contents: Concepts in laboratory medicine, methods, autoimmune disorders involving the connective tissue and immunodeficiency diseases, histocompatibility testing and transplantation, infectious diseases, toxicology, diseases of infancy and childhood, blood vessels.

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Laboratory Medicine
NOTICE Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work. Readers are encouraged to confirm the information contained herein with other sources. For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recommendation is of particular importance in connection with new or infrequently used drugs.
a LANGE medical book Laboratory Medicine The Diagnosis of Disease in the Clinical Laboratory Second Edition Edited by Michael Laposata, MD, PhD Chairman Department of Pathology University of Texas Medical Branch Galveston, Texas New York Chicago San Francisco Athens Lisbon Madrid Mexico City Milan New Delhi Singapore Sydney Toronto
Copyright © 2014 by McGraw-Hill Education. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher, with the exception that the program listings may be entered, stored, and executed in a computer system, but they may not be reproduced for publication. ISBN: 978-0-07-180555-1 MHID: 0-07-180555-9 The material in this eBook also appears in the print version of this title: ISBN: 978-0-07-180554-4, MHID: 0-07-180554-0. eBook conversion by codeMantra Version 1.0 All trademarks are trademarks of their respective owners. Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark. Where such designations appear in this book, they have been printed with initial caps. McGraw-Hill Education eBooks are available at special quantity discounts to use as premiums and sales promotions or for use in corporate training programs. To contact a representative, please visit the Contact Us page at www.mhprofessional.com. TERMS OF USE This is a copyrighted work and McGraw-Hill Education and its licensors reserve all rights in and to the work. Use of this work is subject to these terms. Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may not decompile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill Education’s prior consent. You may use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited. Your right to use the work may be terminated if you fail to comply with these terms. THE WORK IS PROVIDED “AS IS.” McGRAW-HILL EDUCATION AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. McGraw-Hill Education and its licensors do not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free. Neither McGraw-Hill Education nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom. McGraw-Hill Education has no responsibility for the content of any information accessed through the work. Under no circumstances shall McGraw-Hill Education and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages. This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise.
To Susan, with love
Key Features of Laboratory Medicine A complete full-color guide to selecting the correct laboratory test and accurately interpreting the results—covering the entire ﬁeld of clinical pathology • 46 laboratory methods presented in easy-to-understand illustrations which include information on the expense and complexity of the assays • Features an easy-to-follow, consistent presentation for each disease discussed • More than 200 tables and full-color algorithms encapsulate important information and facilitate understanding • Full-color blood-smear micrographs demonstrate common abnormal morphologies of red blood cells • Valuable learning aids in each chapter, including learning objectives, chapter CHAPTER 10 Diseases of Red Blood Cells 231 outlines, and a general introduction • Extensive table of Clinical Laboratory Reference Values showing the conversions between U.S. and SI units for each value • An essential text for medical students and residents studying clinical pathology, medical technology students, and for practitioners working in a clinical setting FIGURE 10–15 Peripheral blood smear from a patient with large numbers of elliptocytes. FIGURE 10–16 A peripheral blood smear stained with Wright stain showing reticulocytes. • This edition has been enhanced by coverage of genetic test options that are now commonly used in clinical practice. Blood-smear micrographs demonstrate common abnormal morphologies of red blood cells FIGURE 10–17 A peripheral blood smear showing FIGURE 10–18 A peripheral blood smear from a patient circulating nucleated red blood cells (arrowheads), as with stomatocytes. well as Howell–Jolly bodies (arrows).
CHAPTER 22 The Endocrine System 423 [–] Hypothalamus Thyrotropin-releasing hormone (TRH) [+] [–] Pituitary Thyroid-stimulating T3 200 tables and full-color algorithms hormone (TSH) T4 [+] Thyroid rT3 T3 is primary feedback stimulus encapsulate important information FIGURE 22–2 Hypothalamic–pituitary–thyroid interactions. [+] Stimulation; [−] inhibition. 426 CHAPTER 22 The Endocrine System hormone replacement in hypothyroid patients. Third-generation assays are essential for monitor- ing TSH suppression therapy in patients with a TSH-responsive thyroid tumor. The relationship between TSH and the thyroid hormones, particularly free T4, is an inverse log-linear one, such that very small changes in free T4 result in large changes in TSH. Thus, TSH TABLE 22–1 Laboratory Evaluation of Patients for Thyroid Disease is the most sensitive first-line screening test for suspected thyroid abnormalities. If the TSH is Laboratory Test Results Suggestive of Diagnosis in the Appropriate Disorder Clinical Setting within the normal reference range, no further testing is performed. If the TSH is outside of the reference range, a free T4 is obtained. Hyperthyroidism Graves disease TSH low; free T4 high; in some cases, T3 is elevated and free T4 is normal; TRAbs or TSI elevated Uptake into cells Toxic multinodular goiter TSH low; free T4 and T3 normal or high; normal or increased radioactive iodine uptake; thyroid scan with multiple areas of increased uptake surrounded by Oral intake Plasma producing thyroid homone Thyroidal suppressed uptake of iodine iodide iodide Toxic adenoma TSH low; free T4 and T3 normal or high; normal or increased radioactive iodine uptake; thyroid scan with focal increased uptake in tumor surrounded by Binding of iodide suppressed uptake in nontumor tissue to thyroglobulin Subacute thyroiditis TSH low; free T4 and T3 high; increased; decreased radioactive iodine uptake Painless thyroiditis TSH low; free T4 and T3 high; erythrocyte sedimentation rate normal; Coupling of Monoiodotyrosine decreased radioactive iodine uptake Proteases Thyroglobulin iodotyrosines (MIT) and Free T4 release T3 bound Hypothyroidism diiodotyrosine and T4 from T3 and T4 (DIT) residues on Hashimoto thyroiditis TSH high; T4 normal and then low, preceding a decline in T3; anti-TPO and/or thyroglobulin thyroglobulin antithyroglobulin antibody positive Ablative hypothyroidism TSH high; free T4 and T3 low following procedure that ablates thyroid Deiodination Infantile hypothyroidism TSH high; free T4 low in a newborn or infant Free T3 Thyroid hormones Euthyroid sick syndrome TSH normal to high; free T4 normal; T3 low; rT3 high; concentrations of TSH and transported to tissues thyroid hormones vary throughout disease course on thyroid-binding rT3, reverse triiodothyronine; T3, triiodothyronine; free T4, free thyroxine; TSH, thyroid-stimulating hormone; TRAbs, TSH receptor globulin (TBG), transthyretin, autoantibodies; TSI, thyroid-stimulating immunoglobulins. Reverse and albumin Diverse metabolic T3 (rT3) effects on target cells may have exophthalmos, emotional changes, menstrual changes, and a fine tremor of the hands. In the presence of a clinical history and physical examination consistent with hyperthyroidism, Free T4 a diagnosis of hyperthyroidism (but not necessarily its cause) can be established by the demon- stration of a low TSH level and a high free T4. In uncommon situations, only the total T3 level FIGURE 22–3 The formation, secretion, and transport of thyroid hormones. is elevated and the serum free T4 is normal (T3 thyrotoxicosis). To determine the etiology of the hyperthyroidism, additional testing is usually necessary. Graves disease, toxic multinodular goiter (TMNG), and toxic adenoma account for the vast majority (>95%) of cases of hyperthyroidism. It should be noted that diffuse or focal enlargement of the thyroid gland, also known as goiter, can be associated with hyperfunction, normal function, and hypofunction of the gland. Thyroid Storm Thyroid storm is a relatively uncommon, but life-threatening manifestation of hyperthyroid- ism caused by excess circulation of thyroid hormones. Symptoms of thyroid storm are similar, Graves disease is a but much more severe than traditional hyperthyroidism, including a markedly high fever of relatively common 105°F to 106°F, tachycardia, hypertension, and neurological and gastrointestinal abnormali- hyperthyroid disorder ties. Thyroid storm is precipitated by acute illnesses such as sepsis, diabetic ketoacidosis, and occurring more preeclampsia, as well as surgical or other diagnostic or therapeutic actions such as radioac- frequently in women. tive iodine use, anesthesia, excessive thyroid hormone ingestion, or thyroid palpation. Thyroid It is an autoimmune storm is associated with a high fatality rate if not identifi ed early. The diagnosis is based on the disease caused by TSH presence of clinical signs and symptoms of severe hyperthyroidism in the context of a precipi- receptor autoantibodies tating cause. In addition, marked elevations in free and total T4 are common in thyroid storm. that bind to and stimulate Total T3 is unreliable in this setting because concomitant nonthyroidal illness (NTI) may cause TSH receptors resulting in T3 to decrease significantly. autonomous production of thyroid hormone. Graves Disease Graves disease is a relatively common hyperthyroid disorder occurring more frequently in women. It has a familial predisposition. It is an autoimmune disease caused by TSH receptor C H A P T E R Breast Karin E. Finberg 21 LEARNING OBJECTIVES 1. Learn the tissue- and serum-based biomarkers in breast cancer. 2. Understand how the individual biomarkers are used clinically. CHAPTER OUTLINE Introduction 413 Hereditary Breast and Ovarian Breast Cancer 413 Cancer Syndrome 417 Laboratory Testing 414 Other High-penetrance Cancer Tissue-based Biomarkers Predisposition Genes 418 in Breast Cancer 414 Li-Fraumeni Syndrome 418 Serum-based Biomarkers Cowden Syndrome 418 in Breast Cancer 416 Peutz-Jeghers Syndrome 419 INTRODUCTION This chapter focuses on laboratory testing relevant to breast cancer. Infections of the breast are included in Chapter 5. BREAST CANCER Description Cancers of the breast constitute a major cause of mortality in women of Western countries. In the United States, the lifetime probability that a woman will develop breast cancer is 1 in 8. Breast cancer accounts for 29% of new cancer cases and 14% of cancer deaths in American women. About 1% of breast cancers occur in males. The risk of developing breast cancer is influenced by several factors. These factors include increased age, family history of breast cancer (especially in a first-degree relative), hormonal factors (early age at menarche, older age of menopause, older age at first full-term pregnancy, fewer number of pregnancies, and use of hormone replacement therapy), clinical factors (high breast tissue density and benign breast diseases associated with atypical hyperplasia), obesity, and alcohol consumption. Since 1990, the mortality rate associated Valuable learning aids are with female breast cancer has decreased in the United States, a decline that has been attributed to both therapeutic advances and early detection. For localized breast cancer, primary treatment typically consists of either breast-conserving surgery and radiation or mastectomy. Most patients with invasive breast cancer subsequently included in each chapter receive systemic adjuvant chemotherapy and/or hormone therapy, both of which have been shown to reduce systemic recurrence and breast cancer-related mortality. However, the fact that some patients who lack lymph node involvement are cured by the combination of sur- gery and radiotherapy suggests that adjuvant treatment may not be necessary in all cases. 413
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Contents Authors xi Preface xiii Acknowledgments xv Clinical Laboratory Reference Values xvii 1. Concepts in Laboratory Medicine 1 13. Diseases of White Blood Cells, Michael Laposata, MD, PhD Lymph Nodes, and Spleen 317 Daniel E. Sabath, MD, PhD 2. Methods 13 Michael Laposata, MD, PhD, 14. The Respiratory System 339 James H. Nichols, PhD Alison Woodworth, PhD Paul Steele, MD, & Thomas P. Stricker, MD, PhD 15. The Gastrointestinal Tract 351 3. Autoimmune Disorders Involving the Michael Laposata, MD, PhD & Connective Tissue and Immunodeficiency D. Robert Dufour, MD, FCAP, FACB Diseases 61 16. The Liver and Biliary Tract 357 Mandakolathur R. Murali, MD William E. Winter, MD 4. Histocompatibility Testing 17. Pancreatic Disorders 371 and Transplantation 83 David N. Alter, MD & Yash P. Agrawal, MD, PhD & Michael Laposata, MD, PhD Susan L. Saidman, PhD 18. The Kidney 385 5. Infectious Diseases 91 William E. Winter, MD Eric D. Spitzer, MD, PhD 19. Male Genital Tract 397 6. Toxicology 159 Mark H. Wener, MD, ABIM, ABAI (CLI/DLI), James H. Nichols, PhD, Sheila P. Dawling, PhD, Charles H. Muller, PhD, HCLD (AAB), & Michael Laposata, MD, PhD & D. Robert Dufour, MD, FCAP, FACB 7. Diseases of Infancy and Childhood 185 20. Female Genital System 405 Paul Steele, MD Stacy E.F. Melanson, MD, PhD & 8. Blood Vessels 197 Ann M. Gronowski, PhD Michael Laposata, MD, PhD 21. Breast 413 9. The Heart 209 Karin E. Finberg, MD, PhD Fred S. Apple, PhD 22. The Endocrine System 421 10. Diseases of Red Blood Cells 221 Alison Woodworth, PhD, Vipul Lakhani, MD, Daniel D. Mais, MD Samir L. Aleryani, PhD, C(ASCP), CLS (NCA), FACB, & Michael Laposata, MD, PhD 11. Bleeding and Thrombotic Disorders 253 Elizabeth M. Van Cott, MD & Index 469 Michael Laposata, MD, PhD 12. Transfusion Medicine 291 Christopher P. Stowell, MD, PhD & Jacqueline J. Haas, MD ix
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Authors Yash P. Agrawal, MD, PhD Jacqueline J. Haas, MD Professor of Clinical Pathology and Laboratory Staff Pathologist, Laboratory Medical Director, Medicine, Department of Pathology and Laboratory Department of Pathology, Clinical Pathology Associates, Medicine; Director of Central Laboratory; Director of St. David’s Medical Center, Austin, Texas Point of Care Testing Services, New York Presbyterian Vipul Lakhani, MD Hospital-Cornell Campus, New York, New York Assistant Professor of Medicine, Department of Samir L. Aleryani, PhD, C(ASCP), CLS (NCA), FACB Medicine, Division of Endocrinology, Vanderbilt Formerly Assistant Professor in Clinical Pathology, University Medical Center, Nashville, Tennessee Director Clinical Research Center Laboratory, Vanderbilt Michael Laposata, MD, PhD Institute of Clinical and Translational Research Chairman, Department of Pathology, University of Texas (VICTR), Department of Pathology, Microbiology, and Medical Branch, Galveston, Texas Immunology School of Medicine, Vanderbilt University, Nashville, Tennessee Daniel D. Mais, MD Clinical Pathology Associates, Department of Pathology, David N. Alter, MD Baptist Health System, San Antonio, Texas Clinical/Chemical Pathologist, Spectrum Health/ Michigan Pathology Specialists, Grand Rapids, Michigan Stacy E.F. Melanson, MD, PhD Assistant Professor, Associate Medical Director, Fred S. Apple, PhD Clinical Chemistry, Clinical Laboratories, Harvard Medical Director, Clinical Laboratories, Hennepin Medical School Brigham and Women’s Hospital, County Medical Center; Professor, Laboratory Medicine Boston, Massachusetts and Pathology, University of Minnesota School of Medicine, Minneapolis, Minnesota Charles H. Muller, PhD, HCLD (AAB) Director, Male Fertility Laboratory and Lecturer, Sheila P. Dawling, PhD Full-Time, Department of Urology and Biological Vice President of Laboratories, Aegis Sciences Structure, University of Washington School of Medicine, Corporation, Nashville, Tennessee Seattle, Washington D. Robert Dufour, MD, FCAP, FACB Mandakolathur R. Murali, MD Consultant, Emeritus Professor of Pathology, Director, Assistant Professor, Department of Clinical Department of Pathology and Hepatology, Veterans Immunology Laboratory, Massachusetts General Affairs Medical Center, The George Washington Hospital, Harvard Medical School, Boston, Massachusetts University Medical, Washington, District of Columbia James H. Nichols, PhD Karin E. Finberg, MD, PhD Professor of Pathology, Microbiology and Immunology; Assistant Professor of Pathology, Yale School of Medical Director of Clinical Chemistry, Vanderbilt Medicine, New Haven, Connecticut University School of Medicine, Nashville, Tennessee Ann M. Gronowski, PhD Professor, Department of Pathology & Immunology and Obstetrics & Gynecology, Washington University School of Medicine, St. Louis, Missouri xi
xii AUTHORS Daniel E. Sabath, MD, PhD Thomas P. Stricker, MD, PhD Associate Professor, Department of Laboratory Assistant Professor, Department of Pathology, Medicine; Adjunct Associate Professor, Department Microbiology, and Immunology, Vanderbilt University of Medicine (Medical Genetics); Head, Hematology School of Medicine, Nashville, Tennessee Division, Department of Laboratory Medicine; Director Elizabeth M. Van Cott, MD of Hematology Laboratories, University of Washington Director, Coagulation Laboratory; Medical Director, Medical Center and Harborview Medical Center, Core Laboratory, Massachusetts General Hospital; Seattle, Washington Associate Professor, Harvard Medical School, Susan L. Saidman, PhD Boston, Massachusetts Associate Professor of Pathology, Harvard Medical Mark H. Wener, MD, ABIM, ABAI (CLI/DLI) School; Director, Histocompatibility Laboratory, Professor, Departments of Laboratory Medicine & Massachusetts General Hospital, Boston, Massachusetts Medicine, University of Washington, Seattle, Washington Eric D. Spitzer, MD, PhD William E. Winter, MD Associate Professor, Department of Pathology, Stony Professor, Department of Pathology, Immunology, and Brook University Medical Center, Stony Brook, Laboratory Medicinem, University of Florida College of New York Medicine, Gainesville, Florida Paul Steele, MD Alison Woodworth, PhD Medical Director, Clinical Associate Professor, Assistant Professor, Medical Director of Esoteric Department of Pathology and Laboratory Medicine, Chemistry, Department of Pathology, Microbiology, and Clinical Laboratories, Cincinnati Children’s Immunology, Vanderbilt University Medical Center, Hospital Medical Center, University of Cincinnati, Nashville, Tennessee Cincinnati, Ohio Christopher P. Stowell, MD, PhD Director, Blood Transfusion Service; Associate Professor of Pathology, Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
Preface In the early 1990s when I was at the Massachusetts General test results by the physicians who ordered the tests is incor- Hospital as director of clinical laboratories, I was invited by rect. A survey of medical schools currently underway has Ramzi Cotran to join him and Stan Robbins at the Brigham shown that the teaching of laboratory medicine over the full and Women’s Hospital for a meeting. In that meeting, they 4 years of medical school includes (as a mean value across indicated to me that the Robbins Pathologic Basis of Disease, the US medical schools) only about 10 hours of formal train- primarily an anatomic pathology book, would greatly benefit ing in laboratory medicine. This study also shows that, unlike from a parallel book in clinical pathology (laboratory medi- virtually every other medical discipline, laboratory medicine cine). At that time, areas such as coagulation and toxicology is commonly not taught by experts in the field, even if they were expanding rapidly with new disorders and new tests to are present in the institution. As a result, medical schools diagnose them. Because there was little anatomic pathology graduate physicians who have had almost no training in in these fields, the discussions of these major areas of diag- something they do virtually every day—order laboratory nostic medicine in the Robbins book were limited. In addi- tests and interpret the test results. Surprisingly, the patients tion, as the test menu in the clinical laboratory was growing and the medical institutions suffer cost and care disadvan- in complexity and cost, many important clinical laboratory tages quietly and unknowingly. There are surely hundreds of tests for common disorders, such as the troponin test for patients every month in the United States who present to an myocardial infarction, were also discussed only briefly in the emergency room with shortness of breath, for whom a diag- Robbins book. Both Robbins and Cotran understood that nosis of pulmonary embolism is overlooked, and an appro- a discussion regarding the threshold for diagnosis of myo- priate test (the D-dimer test for pulmonary embolism) is not cardial infarction, as troponin testing rapidly evolved and ordered. Such patients are discharged from the emergency improved, was necessary to fully discuss the topic. There room without ever being anticoagulated, and for some, to were many twists and turns from that meeting about 20 years die shortly thereafter, from an expansion of the pulmonary ago to the development of this second edition of Laboratory embolism. Like surgical errors or medication errors, the Medicine: The Diagnosis of Disease in the Clinical Laboratory error of the healthcare provider who did not order a neces- in the prestigious Lange series by McGraw-Hill. With this sary test results in a preventable death—but unlike surgical second edition, I believe we truly have a book that is essen- and medication errors, the fact that such a case represents tial for education of medical students and residents study- a preventable death is rarely recognized by the patient, the ing clinical pathology, and importantly, for practitioners in patient’s family, fellow physicians, and often even the physi- a clinical setting. By selecting the correct tests and interpret- cian who failed to order the correct test. ing the results correctly, physicians using this book should There are several groups of healthcare providers who be able to optimize patient outcomes and reduce the cost to would benefit significantly by using this book to correctly achieve a diagnosis. order laboratory tests and correctly interpret the test results. This second edition is a great step forward from the first Certainly, there is every reason to believe that medical stu- edition. It contains information about genetic tests now in dents can learn the histopathologic changes associated with a common use. Additional descriptions of test methods with disease using a textbook such as the Robbins Pathologic Basis simply illustrated figures have been added to this edition. of Disease, and learn laboratory tests associated with that dis- The authors of the individual chapters have all taken sig- order, using this book, at the same time. nificant steps to make the tables that indicate the diagnos- Medical technology students would greatly benefit by a tic tests for different clinical conditions more concise and thorough understanding of the methods that are illustrated in easy to understand. It is now clear that significant morbidity Chapter 2 of this book. In addition, it would be of immense and mortality occur on a daily basis, affecting thousands of benefit for medical technology students to more fully under- patients, because incorrect tests are ordered, important tests stand the clinical significance of the test results that they for the diagnosis are omitted, and/or the interpretation of generate so that they can more knowledgeably interact with xiii
xiv PREFACE physicians who are confused about laboratory test results. order, and importantly, how to interpret the result as well by Interactions between medical technologists and physicians describing common interpretation mistakes – with a much ordering tests that result in improved performance in test higher reliability than virtually all of what is available on the selection and result interpretation would greatly increase the Internet. respect for the medical technologist (also known as clinical It is my greatest hope that the use of this textbook, laboratory scientist) from physicians who use the clinical which presents the entire field of laboratory medicine to a laboratory. large audience of future physicians, medical technologists, In conversations with primary care physicians attempt- and healthcare providers ordering laboratory tests, will ing to select the correct laboratory tests, they often indicate result in better clinical outcomes for patients at a greatly that one of their first inquiries about which laboratory tests reduced cost. to select is to search Wikipedia. It is most likely that there is Michael Laposata a table in this textbook, written by a prominent expert in the Galveston, Texas field, that will tell a practicing physician exactly what test to
Acknowledgments I would first like to acknowledge all the expert chapter authors of the second edition. They are both effective editors. associated with this textbook. Many of them have been I would also like to extend my deepest thanks to the others close professional friends for many years, and I am deeply at McGraw-Hill who have been involved in the production honored to be a colleague of theirs. I also worked closely with of this book. I am delighted that this book has been included Mr. Robert Pancotti at McGraw-Hill in the production of the in the Lange series of medical books, which has such a proud first edition of the book, and Ms. Cindy Yoo in production tradition in medical education. xv
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Clinical Laboratory Reference Values The conventional units in this table are the ones most com- samples and serum samples are unacceptable. For other monly used in the United States. Outside the United States, compounds, both plasma samples and serum samples may SI units are the predominant nomenclature for laboratory test be acceptable. However, there may be differences, often results. The base units in the SI system related to laboratory minor, in the results obtained using plasma versus serum. testing that are found in this table include the mole (amount Potassium is 1 such compound in which reference ranges of substance), meter (length), kilogram (mass), second (time), may be different for plasma and serum. There is a signifi- and Celsius (temperature). cant movement away from the use of serum in favor of Reference ranges vary depending on the instrument and plasma. The principal reason for this is that extra time is the reagents used to perform the test. Therefore, the reference required for samples to clot so that serum may be generated. ranges shown in this table are only close approximations to the A sample collected into a tube with anticoagulant results in adult reference ranges found in an individual clinical labora- the generation of plasma rather than serum after the tube tory. It is also important to understand that reference ranges is centrifuged. The clotting step is omitted when plasma can be significantly affected by age and sex. samples are prepared, and therefore the turnaround time for Conversion factors are provided in the table to allow the the performance of the test is shortened. In some circum- reader to convert conventional units to SI units and vice versa. stances, whole blood is used for analysis, but the number The conversion of the conventional unit to SI unit requires a of tests performed using whole blood is very limited. Urine multiplication with the conversion factor, and conversion of and other body fluids, such as pleural fluid and cerebrospi- the SI unit to the conventional unit requires division by the nal fluid, are also used for testing. Some of the entries in the conversion factor. table are associated with a fluid other than plasma, serum, The sample fluid is sometimes highly restrictive. For or whole blood. example, coagulation tests must be performed using plasma xvii
xviii CLINICAL LABORATORY REFERENCE VALUES Conversion Traditional Factor, Reference Traditional Multiply →, SI Reference Specimen Interval Units ← Divide Interval SI Units Acetaminophen (therapeutic) Serum, plasma 10-30 μg/mL 6.62 70-200 μmol/L Acetoacetic acid Serum, plasma
CLINICAL LABORATORY REFERENCE VALUES xix Conversion Traditional Factor, Reference Traditional Multiply →, SI Reference Specimen Interval Units ← Divide Interval SI Units α-Aminobutyric acid b Plasma 0.08-0.36 mg/dL 97 8-35 μmol/L Amiodarone (therapeutic) Serum, plasma 0.5-2.5 μg/mL 1.55 0.8-3.9 μmol/L δ-Aminolevulinic acid Urine 1.0-7.0 mg/24 h 7.626 8-53 μmol/day Amitriptyline (therapeutic) Serum, plasma 80-250 ng/mL 3.61 289-903 nmol/L Ammonia (as NH3) b Plasma 15-50 μg/dL 0.714 11-35 μmol/L Amobarbital (therapeutic) Serum 1-5 μg/mL 4.42 4-22 μmol/L Amoxapine (therapeutic) Plasma 200-600 ng/mL 1 200-600 μg/L Amylase a,b Serum 27-130 U/L 0.017 0.46-2.21 μKat/L b Androstenedione, male Serum 75-205 ng/dL 0.0349 2.6-7.2 nmol/L b Androstenedione, female Serum 85-275 ng/dL 0.0349 3.0-9.6 nmol/L Angiotensin I Plasma