Understanding Your Lab Results

Terry Watnick, M.D.

Division of Nephrology
The University of Maryland School of Medicine
Baltimore, Maryland

What you will Learn today:

Lab Results-The Basics

CBC: Complete Blood Count
Kidney Labs Basic Metabolic Panel
Bone Labs
Liver Function Studies
Lipid Profile

Why Should you Understand your Lab

Results?
Many Decisions that your health provider
makes are based on your lab tests
Establishing a diagnosis
Developing a course of action for treatment
Monitoring response to therapy

What is in Blood?
WBC: Cells that fight foreign bodies,
infection
RBC: Cells that carry oxygen
Plasma: Contains clotting factors,
fibrinogen
Serum: The part that remains after
fibrinogen is removed & blood clots
Water w/Dissolved proteins (hormones)
Minerals, C02, electrolytes

Example Lab Report

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http://labtestsonline.org/assets/static-pages/SampleReport.html

Panic Values

Critical Results or those that are dangerously abnormal

must be reported to the responsible person and the lab usually makes note of that

What is meant by the Reference Range?

Normal range vs. Reference Range
Established by testing a large population of healthy individuals.
There is usually a range of normal.
Medical data must be interpreted in context.
For example Avg. heart rate is 70, but in a runner 55 may be ok.

Reference range interpreted in the context of the

reference population.
Reference Range may vary with Age, for example Alkaline
Phosphatase made by bone is higher in kids.
Reference Range may with Sex, for example creatinine tends to
be higher in males

What does it mean if my value is out of the Ref. Range?

Statistical Variability-same sample, ~5% may fall outside the
normal range by chance.
Biological Variability, may vary day to day.
Individual Variability: What is normal?

HOWEVER values out of the Ref. Range:

May be significant or indicate a problem that warrants further

investigation.
Analyzed in context of your symptoms, physical exam etc
May need to be repeated:
For the reasons above.

sample wasnt collected properly ie not refrigerated, RBC not

separated from serum.

Lab Results must be interpreted in Context by

your Health Care Provider

The Complete Blood Count or CBC

CBC: Complete Blood Count-I

Evaluates 3 cell types that
circulate in the blood:
WBC (white blood cells)
RBC (red blood cells)
Platelets

Screens for wide variety of

conditions

Infection
Anemia
Inflammation
Bleeding Disorder

CBC: Complete Blood Count-II

WBC (ref range: 4-11K)
Fight Infection, WBC goes up
when there is a bacterial infection
Differential: Major types of WBC:
neutrophils, lymphocytes
Each type of WBC plays a different
role in the body and the numbers
give information about the
immune system
Ex. Eosinophils allergic reactions

CBC: Complete Blood Count-III

Red Blood Cell Count (RBC, ref range 4.1-5.6)
RBC carry oxygen from the lungs, CO2 from body to lungs

Hemoglobin (12.5-17) is the protein in RBC that carries 02

Hematocrit (packed cell volume, ref. 36-50%)
Volume of blood taken up by red cells

Hemoglobin /Hematocrit are best measures of Anemia

Red Cell Indices
Mean corpuscular volume (MCV)
Mean corpuscular hemoglobin (MCH)
Mean Corpuscular hemoglobin concentration (MCHC)

Platelets ( ref range 140K-415K), required for clotting

Too few can cause bleeding, too many clotting

WBC
Decrease
Bone marrow, disorders or
damage
Autoimmune (SLE), diseases of
immune system, HIV
Sepsis -overwhelming infection
Cancer that spreads to the
bone marrow

Increase

Infection, bacterial or viral

Inflammation
Leukemia
Severe Stress
Steroids

Platelet
Decrease
(thrombocytopenia)
Viral infection, hepatitis, mono
Platelet autoantibody,
autoimmune
Cirrhosis
Sepsis
Leukemia, other bone marrow
disorders
Chemo, XRT

Increase

Malignancy
Iron deficiency
RA, SLE, IBD
Essential thrombocytosis

Many Causes of Anemia

Polycythemia

Acute or Chronic Bleeding

Nutritional Deficiencies: Iron,
B12, folate
Inherited: sickle cell,
thalassemia
Bone marrow disorders
Chronic Inflammation: lupus,
infection
Viral: hepatitis, HIV
Any Chronic Disease-renal
failure
Drugs: chemotherapy

Dehydration
Lung Disease, smoking
emphysema
Tumors that produce extra
EPO
Polycythemia Vera

Anemia in Renal Disease

Low RBC/low hemoglobin/low
hematocrit=anemia

Red blood cells carry oxygen to tissues

Anemia is common in renal disease

Can occur early: 20-50% function remains

Kidneys make erythropoietin (EPO),
stimulates bone marrow
Diseased kidneys dont make enough EPO

Treatment

Recombinant EPO, subcutaneously, may

also need iron
Target hemoglobin 10-12, must be
monitored

Functions of the Kidney

Two kidneys, either side of spine.
Each Kidney: 1 million nephrons.
Nephron filters/processes blood to form
urine.

Regulates the amount of fluid and

electrolytes: potassium, calcium &
magnesium.
Waste products ie creatinine are also
filtered.
Kidneys produces 3 hormones:
Erythropoietin, ensures that red blood cells
are produced.
Renin, regulates blood pressure.
Active form of Vitamin ensures calcium is
absorbed from food that we eat.

http://www.nlm.nih.gov/medlineplus/ency/imagepages/19615.htm

Basic/Comprehensive Metabolic Panel

Electrolytes (Na+, K+, Cl-, HC03-)

Electrolyte Levels are Affected by
How much you take in.
The amount of water in your body.
How much you excrete: The kidney is critical in regulating
how you excrete electrolytes.
You can also lose electrolytes in stool and sweat.
Aldosterone, a hormone produced by the adrenal gland
promotes sodium reabsorption, potassium and hydrogen
ion excretion by the kidney.

Sodium, Na+ (ref range: 135-145)

Major positive ion in fluid outside of cells
Brain, muscles, nervous system depend on electrical signals
Movement of Na+ is critical for electrical signals.
Too much or too little causes cells to malfunction.
Extremes in Na+ levels (too much or too little) can be fatal.

Excess Na+ such as that in the diet is excreted by the kidneys

Na+ regulates the total amount of fluid in the body.

Low Na+ or Hyponatremia

Excess water in relation to Na+.

Diseases of the liver, cirrhosis or congestive heart failure.
Excess water drinking.

High Na+ or Hypernatremia

Excess Na+ in relation to water.

Too little water intake, Loss of water ie vomiting or diarrhea.

Potassium (ref range: 3.5-5 meq/L)

Major positive ion inside cells.
Potassium is found in many foods.
Potassium is mostly excreted by
the kidney (~90%).
Potassium is excreted by the GI
tract ~10% under normal
conditions.
Small amount in Sweat.
Aldosterone is a hormone made
by the adrenal gland that is very
important in regulating K+
excretion by the kidney.
Giebisch G, et al, Kidney Int 72: 397-410, 2007

10%

90%

Why is the Potassium level important?

Proper level is important for normal cell function
Regulates heart beat and muscle function

Serious Increase aka hyperkalemia or Serious decrease aka

hypokalemia
Increase the chance of irregular heart beat that can be fatal

The Kidney is critical for getting rid of excess potassium

Small amounts in stool and sweat

If it is <3.5You are in the Low Zone

If it is 3.5-5.0You are in the SAFE zoneIf it is 5.16.0You are in the CAUTION zoneIf it is higher than
6.0..You are in the DANGER zone

Abnormal Potassium
Too High
Too Low
Increased Intake, supplements Poor Intake
Kidney Failure
Loss from GI tract
Acid level high
Vomiting, diarrhea
Tissue Trauma
rhabdomyolysis-muscle
breakdown

Not Enough Aldosterone

Adrenal Failure

Drugs

Angiotensin-converting enzyme
inhibitors ACE
Certain Diuretics (aldactone,
triamterene)
Bactrim

Excessive laxative use

Diuretics
HCTZ, Lasix

Excess aldosterone
Excessive Sweating

Other Electrolytes: Chloride/Bicarbonate

Chloride: Cl Ordered with other

electrolytes as part of a
panel.
Helps in the diagnosis of
other electrolyte
abnormalities.
Can be high in dehydration.
Can be high when too much
bicarbonate is lost.
Can be elevated with
diarrhea

Bicarbonate: or total C02

Reflects Acid-Base Balance
Bicarbonate= Acid low

Severe vomiting
Lung Disease (emphysema)
Severe Dehydration
Increased Aldosterone

Bicarbonate = Acid High

Renal failure (Cant excrete)

Diabetic ketoacidosis
Chronic diarrhea
Salicylate, methanol, ethylene
glycol
Decreased aldosterone

Basic/Comprehensive Metabolic Panel

What is Glomerular Filtration Rate or GFR?

How well the kidneys are
working: The volume of
filtrate produced per
minute.
Normally Kidneys filter 180
Liters of blood per day.
Only 1-2 Liters of urine.
99% reabsorbed into blood.
Composition of urine
modified by
secretion/reabsorption.

How do we determine Renal Function or GFR?

In Clinical Practice the plasma concentrations of
waste substances such as creatinine and urea
(BUN) are used to estimate renal function.

Measurements of Renal Function, BUN

Blood Urea Nitrogen or BUN (Reference Range: 6-24).
Urea is produced in the liver when protein is broken
down to amino acids.
Urea released into the blood where it is filtered and
excreted by the kidneys.
Conditions that affect the kidneys and or liver can affect
the amount of urea in the blood.
A High BUN implies impaired Kidney function

BUT BUN can be elevated for reasons other than

kidney damage
Any condition that results in decreased blood flow
to the kidneys such as congestive heart failure.
Severe Dehydration
GI bleeding
Increased Catabolism or protein breakdown
Increased Protein in the diet
Steroids such as prednisone

Low BUN not usually a cause for concern can be

seen in severe liver disease or malnutrition

Other Measurements of Renal Function

Creatinine is the best measure of renal function:
Reference range: 0.7 to 1.3 mg/dL for men and 0.6
to 1.1 for women
Muscular young adults may have more, elderly less

Produced continuously from muscle breakdown

Kidneys filter creatinine from blood into the urine
Amount of blood that is cleared of creatinine each
minute is called the creatinine clearance.
Creatinine clearance is a good approximation of
the glomerular filtration rate or GFR

Can we estimate GFR from Creatinine?

YES! Glomerular Filtration Rate can be estimated from serum
creatinine measurements.
Calculated using the Modification of Diet in Renal Disease
Equation MDRD, referred to as eGFR.
GFR (mL/min/1.73 m2) = 175 (Scr)-1.154 (Age)-0.203
(0.742 if female) (1.212 if African American).
Takes into account, gender, age, race.
Most thoroughly validated equation
Caucasians, African Americans ages 18-70 w/GFR< 60

More useful than creatinine alone, why?

Same creatinine: Very Different GFR

http://www.kidney.org/professionals/kls/pdf/12-10-4004_KBB_FAQs_AboutGFR-1.pdf

 Taking supplements
Obese, amputees

Creatinine must be stable

Not in pregnancy
Acute illness, hospitalized patients
Acute Kidney Injury

Will under estimate kidney

function in those with near normal
function
Captures only some non-GFR
determinants of creatinine
http://nkdep.nih.gov/

Overestimate Under Estimate

Not for non-adults

Patients with extremes in muscle
mass or diet

Measured-Estimated GFR ml/min/1.73 m2

Limitations of eGFR: Still an estimate

Estimated GFR ml/min/1.73 m2

Validation Set N=3896 NHANES

Levey and Stevens, Frequently Asked Questions

About GFR Estimates, copyright National Kidney
Foundation, 2004.

Other Methods for Measuring GFR

CKD-EPI equation
May be more accurate at higher kidney function GFRs
Not as well validated as MDRD

24 hr urine collection for creatinine, simultaneous blood Cr,

UV/P1440
Over estimate at low GFRs, eGFR using MDRD is more accurate
Relies on accurate collections, may need to repeat multiple times
Can be useful when eGFRs suspected to be inaccurate

Inulin, iothalamte, iohexol Clearances

These may be accurate but they are research tools

Stages of Chronic Kidney Disease (CKD)

Urinalysis

Urinalysis

Proteinuria: Protein in the urine

Protein in the urine/proteinuria may
be the first sign of kidney disease
Can be measured by dip stick or urine
albumin/creatinine ratio.
>30mg/g abnormal
30-300 mg/g microalbuminuria
>300 mg/g macroalbuminuria
24 hour urine collection: >3g/24h
considered to be nephrotic range
ADPKD is not usually associated with
nephrotic range proteinuria

Glomerular ultrafiltrate should

not contain protein

Basic/Comprehensive Metabolic Panel

Why Bone?
When the Kidney isnt
working (Stage3-4):
Phosphate:
Active form of Vitamin D:

This results in lower calcium

Signals to the parathyroid
gland to make more PTH.
This causes bone disease.
Your Doctor may check your
Intact PTH level
Rx: Active form of 1, 25
VitaminD

Ref Ranges: Calcium (8.7-10.2)

Phosphorus (2.5-4.5)

Liver Function Tests LFTs

Purpose to monitor liver disease or function

ALT and AST: Enzymes found in the liver cells used to detect liver damage
ie from hepatitis, drugs
Alkaline phosphatase: produced by bile ducts and rises when this is
blocked. Also made by bone, intestine.
Bilirubin: Break down product of red blood cells, modified in the liver,
secreted in bile and urine. Elevated levels cause jaundice
Albumin is a protein made by the liver, binds to hormones, proteins in the
blood

Fasting Lipid Profile (9-12 hours)

Two types of Lipids transported in blood, cholesterol and Triglycerides, by

particles containing different fats and protein (lipoprotein particles).
Total cholesterol measures all types of cholesterol in these particles.
HDL or good cholesterol : excess cholesterol to the liver for removal.
LDL or bad cholesterol: Deposits in blood vessels.
Lipid Profile: part of a cardiac risk assessment-risk of heart disease
Treatment depends on the results and other risk factors.
May include life style changes ie diet and exercise, medications.

Questions???

Helpful References
National Kidney Disease Education Program:
http://nkdep.nih.gov/index.shtml
Lab Tests On Line: http://labtestsonline.org/understanding/
National Kidney Foundation: Frequently asked questions about GFR:
http://www.kidney.org/professionals/kdoqi/gfr.cfm
National Kidney and Urologic Diseases Information Clearing House
(NKUDIC): http://kidney.niddk.nih.gov/index.aspx
GFR
Calculator:http://www.kidney.org/professionals/kdoqi/gfr_calculat
or.cfm
Kidney Function:
http://humanphysiology2011.wikispaces.com/12.+Urology