Results are meaningful only when considered in relation
to other data such as state of health/illness, salt intake and
1. Normal findings: Urinary excretion of chloride
decreases to a very low level whenever the serum level
a. In some conditions, urinary excretion of chloride
increases even when the serum level is as low as
85 mEq/liter or less. Occurs in Addison’s disease
when there is a deficiency of adrenal hormones
that controls the excretion of sodium and chloride.
b. Decreased levels are also associated with:
3. Increased levels are associated with:
• Mercurial and chlorothiazide diuretics.
1. Urinary chloride concentration varies with dietary salt
intake, perspiration and to some extent, with urine
2. False elevations may occur if the patient has taken
The test is indicated in the study of renal and adrenal
disturbances and of water and acid-base imbalances.
Use colorimetric, flame photometry or ISE method.
Results have significance only when considered in relation
to other data, such as a state of health/illness, salt intake,
• Adrenal cortical insufficiency
• Mercurial and chlorothiazide diuretics
2. Decreased Levels of Sodium Associated with
Often accompanied by an equivalent loss of chloride.
Test is required to assess electrolyte balance of the
body by measuring the amount of potassium excreted
in 24 hours. This measurement is useful in the study of
renal and adrenal disorders and of water and acid-base
Use colorimetric, flame photometry or ISE method.
• Diabetic and renal tubular acidosis
• Mercurial chlorothiazide, ammonium chloride, and
• Adrenal cortical insufficiency (in some cases)
• Excessive mineralocorticoid activity (aldosterone)
• In patients with potassium deficiency, regardless of
• In excessive vomiting or stomach suctioning, the
accompanying alkalosis maintains urinary potassium
excretion at levels inappropriately high for the degree
• In diabetes insipidus, urinary potassium is normal.
Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH)
Midcycle : Over three times baseline.
These investigations are required in determining whether
a gonadal insufficiency is primary or due to deficient
stimulation by the pituitary hormones. The production
of these hormones is under control of pituitary gland. In
women, FSH promotes maturation of the ovarian follicle,
and the maturing follicle produces estrogens. As the levels of
estrogen rise, luteinizing hormones are produced. Together,
FSH and LH induce ovulation. In men, FSH produces
spermatogenesis, and LH induces the secretion of androgens.
men. In primary ovarian failure or testicular failure, FSH is
Use regular ELISA/CLIA/RIA based methods for estimation.
Blood and urine estimation are used.
¾ Feminizing and masculinizing ovarian tumors when
production is inhibited as a result of increased estrogen
¾ Failure of pituitary or hypothalamus
¾ Neoplasm of testes or adrenal glands that secrete
¾ Hypogonadism and primary gonadal failure
¾ Complete testicular feminization syndrome
¾ Precocious puberty, either idiopathic or secondary to a
Standardization extremely difficult:
Proliferative phase : 0.5–1.5 mg/24 h
The test helps in assessing ovarian and placental
function. It is indicated when a deficiency of progesterone
in conceiving and maintaining a pregnancy. To be specific,
it measures the hormone progesterone and its principal
excreted metabolite, pregnanediol. Progesterone has its
implantation of the blastocyte if fertilization has taken
place. Pregnanediol excretion is high in pregnancy and
low in luteal deficiency or placental failure. A 24-hours
urine sample collection is needed.
Use regular ELISA/CLIA/RIA based methods for esti
• Arrhenoblastomas of the ovary
• Threatened abortion (not always)
Do not confuse this with pregnanediol. Pregnanetriol
reflects one segment of adrenocortical activity. This is a
precursor in adrenal corticoid synthesis and arises from
17-hydroxyprogesterone, not from progesterone. The 24-
hour urine test is conducted to diagnose adrenogenital
syndrome, a defect in 21-hydroxylation.
The diagnosis of adrenogenital syndrome is considered
¾ Adult women who show signs and symptoms of excessive
androgen production with or without hypertension
¾ Infants who exhibit signs of failure to thrive
a virilizing tumor of the adrenal gland, neurogenic and
constitutional types of sexual precocity, and interstitial
Use regular ELISA/CLIA/RIA based methods for estimation.
Elevated pregnanetriol levels occur in:
¾ Congenital adrenocortical hyperplasia
Estradiol (E2) : 0–10 mg/24 h.
Pregnancy - Estriol (E3): 2–30 mg/24 h.
To evaluate ovarian function and gynecologic problems,
estradiol, estron, and estriol are routinely measured.
Estrogens will be normally increased in pregnancy and in
some tumors of the ovary and adrenal cortex.
Estrogens are decreased in the absence of deficiency
of ovarian hormones. Estriol levels are used in the
management of high-risk pregnancies as a method of
assessing placental function. A fall in estriol should be
judged by at least two different serial measurements. A
falling estriol excretion signifies impending fetal death.
Use regular ELISA/CLIA/RIA based methods for estimation.
1. Decreased Estrogen Values are Seen with
• Hypo or dysfunction of pituitary and adrenal glands
2. Increased Estrogen Levels are Found in
• Solid ovarian tumors, granulosa/theca cell
• Tumor/hyperplasia of the adrenal cortex.
• More than 40% of previous values is associated with
placental insufficiency. An abrupt drop of 40% or more
is associated with fetal distress.
4. Miscellaneous Causes of Estriol Level’s Decline are
Heavy Metals and Trace Elements in Blood/ Urine
Heavy metals include antimony, arsenic, bismuth, cadmium,
cobalt, copper, lead, mercury, selenium, thallium, and zinc.
Antimony exposure occurs in miners, smelters, and ore
Arsenic is found naturally in food and the environment
Bismuth exposure occurs in workers in cosmetic,
disinfectant, and pigment industries. It may also occur as a
result of treatment for syphilis.
Cadmium accumulates in the lungs, liver and kidneys
via exposure to food, water, air, and cigarette smoke.
Cobalt, a component of vitamin B12, is found in most
foods. It is also used to treat some resistant anemias and
some radiosensitive malignancies.
Copper is a trace element found in normal diets. It is one
of the few heavy metals that are potentially harmful at low
levels as well as at toxic levels. Toxic levels may be caused
by the use of copper IUDs, ingestion of contaminated
substances, or fungicide exposure.
Lead is absorbed into the body through the ingestion of
lead containing paint or through industrial exposure.
Antimony 0.052 ± 0.019 µg/dL 4.35 ± 1.6 nmol/L
Arsenic 2–23 µg/L 0.03–0.31 µmol/L
Chronic poisoning 100–500 µg/L 1.33–6.65 µmol/L
Acute poisoning 600–9300 µg/L 7.98–124 µmol/L
Bismuth 0.1–3.5 µg/L 0.5–16.7 nmol/L
Smokers 0.6–3.9 µg/L 5.3–34.7 nmol/L
Non-smokers 0.3–1.2 µg/l 2.7–10.7 nmol/L
Toxic 100–3000 µg/L 0.9–26.7 µmol/L
Cobalt 0.11–0.45 µg/L 1.9–7.6 nmol/L
Infants 20–70 µg/dL 3.1–11 µmol/L
Child 6 years 90–190 µg/dL 14.1–29.8 µmol/L
Child 12 years 80–160 µg/dL 12.6–25.1 µmol/L
Adult male 70–140 µg/dL 11–22 µmol/L
Adult female 80–155 µg/dL 12.6–24.3 µmol/L
Pregnant 118–302 µg/dL 18.5–47.4 µmol/L
Industry exposure <60 µg/dL <2.90 µmol/L
Toxic concentration >100 µg/dL >4.83 µmol/L
Mercury 0 6–59 µg/L 3–294 µmol/L
Non-fish eaters <5 µg/L <25 nmol/L
Selenium 58–234 µg/L 0.74–2.97 µmol/L
Mercury is found in fungicides, industrial processes,
and in fish (polluted water). It can also be ingested in
the form of mercury salts. High mercury levels have been
Selenium is a metal used for the activity of human
glutathione peroxidase. Exposure occurs as a result of the
manufacture of glass, paints, dyes, electronic equipment,
fungicides, rubber, and semiconductors.
Thallium is present in cosmetics, pesticides, and in
some medications. It is absorbed through intact skin and
Zinc is a trace metal important for cellular growth and
metabolism. Toxicity can occur from industrial exposure
and consumption of acidic food or beverages from
Normal values are given below:
Arsenic: Gastric pain, vomiting, diarrhea, convulsions,
coma, and death in acute poisoning; and diarrhea,
scaling and pigmentation of skin, hair loss, and peripheral
neuropathy in chronic poisoning.
Bismuth: Weakness, decreased appetite, fever, halitosis,
black gum line, rheumatic type pain, and renal damage.
Cadmium: Pneumonia, pulmonary edema, and cardio -
vascular collapse from inhalation, violent gastrointestinal
symptoms from acute ingestion, and osteomalacia and
renal dysfunction from chronic ingestion.
Cobalt: Thyroid gland hyperplasia, cardiomyopathy, nerve
Copper: Nausea, vomiting, headache, diarrhea, and
Lead: Anorexia, abdominal pain, vomiting, irritability, and
Mercury: Fatigue, headache, loss of memory, apathy,
emotional instability, paresthesia, ataxia, deafness,
dysarthria, visual deterioration, dysphagia, coma, and
Selenium: Garlic smell in breath and urine, metallic taste,
headaches, nausea, vomiting, pneumonia and pulmonary
Thallium: Ataxia, pulmonary edema, vomiting,
constipation, restlessness, delirium and coma.
Zinc: Cough, chest discomfort, tachycardia, hypertension,
gastrointestinal irritation, nausea, vomiting, diarrhea, and
Antidotes for heavy metal poisoning include BAL
(British anti-Lewisite), deferoxamine, dimercaprol, and
EDTA. Heavy metals respond to hemodialysis and/or
hemoperfusion in varying degrees (poor to well).
Screening for heavy-metal toxicity from overexposure,
ingestion, or occupational exposure. Disorders for
individual metals found under test listings for individual
metals. Drugs that may further increase some values
include carbamazepine, estrogens, oral contraceptives,
penicillamine, phenobarbital, phenytoin, and sodium
MICROSCOPY OF THE URINARY SEDIMENT
Use a clean, fresh morning specimen. Obtain urinary
sediment by centrifuging urine at 3000 rpm for 5 minutes.
Draw off the clear supernatant fluid, place a drop of the
sediment on a glass slide and cover it with a coverslip.
Examine first under low power, then under high power,
vary the light intensity for seeing casts. If protein is present,
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