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S.Y. 2024-2025

Lesson

PROTEINS
MT 311 - CLINICAL CHEMISTRY
UY KIENG, NICOLE | SALAZAR, YSIS | ABEGONIA, ANDREI
BMLS 3A

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CLINICAL CHEMISTRY LECTURE 
TARRAYO, ODETTE MAFFI| S.Y. 2024-2025

TOPIC: PROTEINS
DECEMBER 11, 2024
LEGEND : BLACK and RED - PPT
GREEN- RECORDING

Proteins are large, complex molecules that play amino acid linking with the carboxyl group of
various important roles in the body. They are another, forming a peptide bond.
critical to most of the work done by cells and are
required for the structure, function, and
regulation of the body's tissues and organs.

AMINO ACID
→ are the building blocks of proteins

→ The chemical properties of the amino acids

of proteins determine the biologic activity of
the protein. Growth, repair, and maintenance of
all cells are dependent on amino acids.

BASIC STRUCTURE
→ An amino acid contains an alpha carbon that
always has four substituents and is
tetrahedral, all except proline, of an amino
group, a carboxylic acid group, an alpha diagram So as you can see here, this is where
hydrogen, and a specific side chain known as the peptide bond forms. An may square.
the R group. It's between the carboxyl group of one amino
acid and the amino group of another amino acid.
And to form the peptide bond, H2O is released.
That's OH from the carboxyl group and an H ion
from the amino group.

→ A chain of amino acids is also known as a

polypeptide, and a large polypeptide
constitutes a protein.
TLE → Amino acids differ from one another by the
chemical composition of their R group (side
diagram here we have the alpha carbon, the
chains).
alpha hydrogen, the amino group of the amino
acid, the carboxyl group or carboxylic acid
group, and the side chain.

→ The N-terminal end amino group (-NH2)

and the C-terminal end carboxyl group bond
to the alpha carbon with the amino group of one

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CLASSIFICATIONS

Non-polar aliphatic- are the hydrophobic amino

acids.

Non-polar aromatic- are the amino acids that

Histidine has an imidazole group
contain a benzene ring in their structure.

Polar uncharged- amino acids are hydrophilic.

Tryptophan has an indole group

METABOLSIM
→ About half of the 20 amino acids needed
by humans cannot be synthesized at a rapid
enough rate to support growth. They must be
supplied in food in the form of dietary
proteins.

diagram essential means that you have to

supply it from the diet, while non-essential
amino acids are regularly produced by our body.
Glycine is the smallest and simplest amino acid.
The two sulfur-containing amino acids are
cysteine and methionine.

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One example of a non-essential amino acid is

tyrosine.

TYROSINE
→ is produced from phenylalanine. It is
phenylalanine that is an essential amino acid.
So, if the diet is deficient in phenylalanine,
tyrosine will be required as well.

→ is produced from phenylalanine through a

process call hydroxylation, which is catalyzed
by the enzyme phenylalanine hydroxylase
(PAH)

→ Under normal circumstances, proteolytic

enzymes such as pepsin and trypsin,
completely digest dietary proteins into their
constituent amino acids. Amino acids are then
rapidly absorbed from the intestines into the
blood and become a part of body's pool of
amino acids.
Amino acids are primarily absorbed in the small
AMINO ACID ADSORPTION
intestine, with most absorption taking place in
the jejunum, which is the middle part of the
small intestine. So in this illustration, we have
here the lumen, which is the space within a tube
or cavity in the body. And then we have your
enterocyte, or intestinal absorptive cells. They
are simple columnar epithelial cells, which line
the surface of the small and large intestines.
Now as you can see in this illustration, we have
here your dietary proteins. They are acted upon
by pepsin and pancreatic peptidases. Pepsin is
the chief digestive enzyme in the stomach,
which breaks down proteins into polypeptides.

There are two types of pancreatic peptidases.

They are your endopeptidases and
exopeptidases.

Endopeptidases break peptide bonds along the

polypeptide chain to produce smaller peptides.
Examples of endopeptidases include trypsin,
chymotrypsin, and elastase.

Exopeptidases, on the other hand, attack either

the carboxy-terminal or amino-terminal peptide
bonds, releasing single amino acids. Examples of
exopeptidases include carboxypeptidase A and
carboxypeptidase B.

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So again, endopeptidases produce smaller

peptides, while exopeptidases produce single
amino acids.

We also have here your brush border

peptidases, which again breaks down
polypeptides or smaller peptides into single
amino acids.

So that was the breakdown of dietary proteins

into oligopeptides and amino acids.

Now we move on to the absorption of these

amino acids. We have your oligopeptide co-
transporter and amino acid co-transporters.
They are co-transporters because they require
certain ions in order to absorb small
oligopeptides and single amino acids.

Oligopeptide co-transporter requires a hydrogen

ion in order to absorb small oligopeptides, Amino acids can enter the Krebs cycle once they
are metabolized or broken down into the
Amino acid co-transporters require sodium ions
intermediates of the Krebs cycle. For example,
in order to absorb single amino acids.
we have alanine. Alanine is converted to
Once inside the enterocyte, the small pyruvate through a reaction catalyzed by the
oligopeptides are acted upon by peptidases and enzyme alanine aminotransferase. It is an
are then transported by the amino acid enzyme otherwise known as SGPT. It is a liver
transporter, which then enters the circulation. enzyme.

→ The amino group is removed from amino

acids by either deamination or
transamination. The resultant ketoacid can
enter into a common metabolic pathway with
carbohydrates and fats.

Here we have the glucogenic amino acids and

the ketogenic amino acids. Your isoleucine,
phenylalanine, threonine, tryptophan, and
tyrosine are both. They are both glucogenic and
ketogenic.

→ The ammonium ion that is produced during

deamination of the amino acid is converted
into urea via the urea cycle in the liver.

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Amino acids are deaminated to break down → The metabolic defect is an absence of activity
excess amino acids for energy and to remove of the enzyme phenylalanine hydroxylase
toxic nitrogen waste from the body. (PAH), which catalyzes the conversion of
phenylalanine to tyrosine.
PURPOSE
→ The primary purpose of amino acids is for the So that is where the defect in phenylketonuria
synthesis of body proteins, including plasma, lies. There is a defect in the enzyme
intracellular, and structural proteins. phenylalanine hydroxylase or PAH.

→ Chronically high levels of phenylalanine and

Amino acids are also used for the synthesis of
some of its metabolites, such as the
non-protein nitrogen containing compounds
phenylpyruvic acid, phenylpyruvate, and
such as purines, pyrimidines, porphyrins,
phenyllactic acid, can cause significant
creatine, histamine, pyroxene,
problems.
epinephrine, and the coenzyme NAD.
So an accumulation of these metabolites can
In addition, protein provides 12 to 20% of the cause significant brain problems.
total daily body energy requirement.
→ All these compounds are found in both the
AMINOACIDOPATHIES blood and urine of a PKU patient, giving the
→ are a class of inherited errors of metabolism urine a characteristic musty odor.
in which there is an enzyme defect that
So if you can remember, phenylalanine is one of
inhibits the body's ability to metabolize certain
the aromatic amino acids. It has a benzene ring
amino acids.
in its structure, which is why in increased levels,
→ The abnormalities in amino acidopathies exist it can give the urine of a PKU patient a
either in the activity of a specific enzyme in characteristic odor. In this case, a musty odor.
the metabolic pathway, or in the membrane
→ In infants and children with this inherited
transport system for amino acids.
defect, retarded mental development and
So again, in amino acidopathies, the problem microcephaly occur as a result of the toxic
lies with an enzyme defect. effects of phenylalanine or its metabolic
byproducts on the brain.
→ Aminoacidopathies cause severe medical
complications due to the buildup of toxic
amino acids and or byproducts of amino acid
metabolism in the blood.

So that is because amino acids have to be

metabolized and their byproducts have to be
removed from the body, or else they will end up
causing severe medical complications because We have here an illustration. This is a child with
they are toxic to the body. normal head size. This is a child with
microcephaly. As you can see, there is a
So the first amino acidopathy that we will be significant difference. So this is what a child with
discussing is phenylketonuria. microcephaly looks like in the case of
PHENYLKENTONURIA phenylketonuria.
→ It was the first newborn screening test → For the treatment of PKU, the goal is to
introduced in the 1960s. Now some countries maintain the blood level of phenylalanine
and states require screening tests for up to 26 between 2 and 10 mg per deciliter (120 to
amino acids. 600umol/L) , usually via restrictions in diet.

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So again, in the case of phenylketonuria, they abnormal sensitivity to light, eye pain and
lack the enzyme that metabolizes phenylalanine. redneck, and painful skin lesions on the
So there is a buildup of phenylalanine in their palms and soles of the feet.
circulation. So to minimize that, they have to
limit their intake of foods rich in phenylalanine. TYPE III TYROSINEMIA
→ It is a rare disorder caused by a deficiency of
→ For the testing of PKU, the Guthrie test is 4-hydroxyphenyl pyruvate dioxygenase.
a semi-quantitative bacterial inhibition assay for This enzyme is found mainly in the liver with
phenylalanine that uses the ability of lesser amounts in the kidneys.
phenylalanine to facilitate bacterial growth
→ The clinical picture of type 3 tyrosinemia
(Bacillus subtilis) in a culture medium with an
inhibitor beta-2-thiemylalanine. patients includes mild mental retardation,
seizures, and periodic loss of balance and
→ In recent years, it is gradually being replaced coordination.
by newer techniques such as tandem mass
spectrometry or MS-MS, which is the gold ALKAPTONURIA
→ It is an inborn metabolic disease transmitted
standard for detecting a variety of congenital
diseases. as an autosomal recessive gene, the HGD
gene, which causes the lack of the enzyme
TYROSINEMIA homogentisate oxidase, which is needed in
→ The inborn metabolic disorders of tyrosine the metabolism of phenylalanine and tyrosine.
catabolism are characterized by the excretion
of tyrosine and tyrosine catabolites in c A predominant clinical manifestation is that the
patient's urine turns brownish-black when it
urine. There are three types of tyrosinemia,
mixes with air. This phenomenon is due to an
each with distinctive symptoms and caused by
the deficiency of a different enzyme. accumulation of homogentisic acid (HGA), in
the urine, which oxidizes to produce this dark
TYPE I TYROSINEMIA pigment.
→ It is the most severe form of this
aminoacidopathy. It is caused by low levels of → Patients with alkaptonuria have no immediate
problems. However, late in the disease, the high
the enzyme fumarylacetoacetate hydrolase,
the fifth of five enzymes needed to break down level of HGA gradually accumulates in the
tyrosine. connective tissue, causing ochronosis
(pigmentation of these tissues), an arthritis-
→ Symptoms include failure to thrive, diarrhea, like degeneration from the buildup of HGA in
vomiting, jaundice, cabbage-like odor of urine the cartilage, dark spots on the sclera, and
or sweat, distended abdomen, swelling of legs, deposition of pigment in the cartilage ears,
and increased predisposition for bleeding. It can nose, and tendons of the extremities.
lead to liver and kidney failure and problems
So, again, you will notice that the problem lies in
affecting the nervous system or the central
nervous system. the fact that HGA builds up in connective tissues
of patients with alkaptonuria. Symptoms usually
TYPE II TYROSINEMIA show in mid-adulthood, around age 30 to 40
→ It is caused by a deficiency of the enzyme years old.
tyrosine aminotransferase, which is the first
in a series of five enzymes that converts tyrosine
to smaller molecules to be excreted by the
kidneys or used in energy-producing reactions.

→ About half of the individuals with this disorder

are mentally retarded and have symptoms of
epiphora (excessive tearing), photophobia or

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OTHER AMINOACIDOPATHIES
1. ISOVALERIC ACIDEMIA
2. HOMOCYSTINURIA
3. CITRULLINEMIA
4. ARGININOSUCCINIC ACIDURIA
5. CYSTINURIA

here we have the urine sample of a patient with PROTEINS

alkaptonuria. This is their urine that is freshly → are biopolymeric structures composed of
collected, and then this is their urine after an amino acids.
hour of standing. So, it turns into a brown to
black color. Then, we have here the deposition
of HGA in the cartilage of the ears of patients
with alkaptonuria, here in the tendons and in
the sclera.

MAPLE SYRUP URINE DISEASE (MSUD)

→ It is an autosomal recessive disorder
characterized by an absence or greatly reduced
activity of the enzyme alpha-ketoacid
decarboxylase, blocking the normal
Proteins have various important roles in the
metabolism of the three essential branched
body. For example, enzymes are made up of
chain amino acids leucine, isoleucine, and valine.
proteins. Antibodies are made up of proteins.
→ The most striking feature of this hereditary Our digestive enzymes help facilitate chemical
disease is the characteristic maple syrup or reactions. Antibodies support immune function.
burnt sugar odor of the urine, breath, and
Proteins also support muscle contraction and
skin. The result of this enzyme defect is an
movement. They support the regulation and
accumulation of the branched chain amino acids
expression of DNA, provide support to the body.
and their corresponding ketoacids.
Hormones, specifically peptide hormones, help
→ Infants with MSUD seem normal at birth, coordinate bodily function, and they move
but, within a week, will develop lethargy, essential molecules around the body because we
vomiting, lack of appetite, and signs of failure to have transport proteins such as hemoglobin.
thrive. CNS symptoms follow, including muscle
BASIC STRUCTURE
rigidity, stupor, and respiratory irregularities.
→ Proteins consist of the elements carbon,
→ The disease progresses to cause severe oxygen, hydrogen, nitrogen, and sulfur. The fact
mental retardation, seizures, acidosis, and that proteins contain nitrogen (16%), sets
hyperglycemia. If treatment is not given, the them apart from pure carbohydrates and lipids,
disease can lead to death. The modified which do not contain nitrogen atoms.
Guthrie test is commonly used for neonatal
→ Proteins are polymers built from one or
screening, using 4-azoleucine as an inhibitor
more chains of amino acids. A typical protein
to be subtilis.
contains 200 to 300 amino acids, but some are
So, you will notice that the difference between much smaller (e.g., insulin has 51 amino acids)
the Guthrie test and the modified Guthrie test is or larger (e.g., titin in muscle has 27,000 to
the inhibitor used. 35,000 amino acids.)

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→ There are four distinct levels of the protein SECONDARY STRUCTURE

structure. your primary, secondary, tertiary, → Secondary structure is the regularly
and quaternary. repeating structures stabilized by hydrogen
bonds between the amino acids within the
protein. Common secondary structures are the
alpha helix and beta-plated sheets. It adds
properties to a protein, such as strength and
flexibility.

So some proteins have both alpha helices and

beta-plated sheets, while some only have either
one. For example, the hemoglobin is an all-
helical structure.

PRIMARY STRUCTURE
→ Primary structure represents the number
and types of amino acids in the specific amino
acid sequence. In order to function properly,
proteins must have the correct sequence of
amino acids.

Now, as you can see in this illustration of a

protein's secondary structure, we have here two
chains of amino acids connected by hydrogen
bonds.

TERTIARY STRUCTURE
→ Tertiary structure refers to the overall
shape or conformation of the protein molecule.
Again, they cannot be interchanged. For The conformation is known as the fold or the
example, the sickle cell mutation causes spatial relationship of the secondary structures
substitution of glutamic acid to valine as the to one another.
seventh amino acid in the beta-globin chain. So → Tertiary structure results from the interaction
this is what a normal hemoglobin molecule looks of side chains and is stabilized through the
like, and this is what it looks like in sickle cell hydrophobic effect, ionic attraction, hydrogen
anemia. Sickle cell hemoglobin forms long bonds, and disulfide bonds. The function and
inflexible chains. Why? A normal red blood cell is physical and chemical properties of a protein
round and concave, while a sickle cell is depends on its tertiary structure.
elongated and inflexible.

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Now, please remember that disulfide bonds are → When the secondary, tertiary, or quaternary
formed between two cysteine molecules. structure of a protein is disturbed, the protein
may lose its functional and chemical
characteristics. This loss of its native or naturally
occurring folded structure is called
DENATURATION.

→ Denaturation can be caused by heat,

hydrolysis by strong acid or alkali,
enzymatic action, exposure to urea or other
substances, or exposure to ultraviolet light.

CLASSIFICATION BY FUNCTIONS
ENZYME
→ are proteins that catalyze chemical
Now, in this illustration, we can see that this reactions normally found inside cells but are
protein molecule has both alpha helix and beta- released to the blood in tissue damage, making
plated sheets. We have here hydrogen bonds, enzyme measurement a very important
ionic bonds, and disulfide bonds. Now, diagnostic tool.
hydrophobic interactions are when nonpolar
aliphatic amino acids cluster together towards So for example, we have the liver-specific
the center or inwards into the protein molecule enzyme alanine aminotransferase or ALP or
because, again, these amino acids are SGPT. It is normally found within hepatocytes,
hydrophobic, so they tend to avoid the part of but in the case of liver damage, it is released
the protein that interacts with the fluid from inside the cells into the blood where it is
surrounding it. measured to assess the extent of liver damage.

QUATERNARY STRUCTURE HORMONES

→ Quaternary structure is defined as the → specifically the peptide hormones. They are
shape or structure that results from the proteins that are chemical messengers that
interaction of more than one protein molecule or control the actions of specific cells or organs.
protein subunits held together by the non- Hormones affect growth and development of
covalent forces such as hydrogen bonds and metabolism, sexual function, reproduction, and
electrostatic interactions, creating a complex behavior.
and precise three-dimensional
TRANSPORT PROTEINS
configuration.
→ are proteins that facilitate the movement
of ions, small molecules, or macromolecules
such as hormones, vitamins, minerals, and lipids
across a biologic membrane.

So for example, we have the sodium-potassium

bond, which facilitates the movement of sodium
and potassium ions across the cell membrane.
So, to summarize, the primary structure is the
So those are made up of proteins. We also have
chain of amino acids. The secondary structure is
carrier proteins such as transferrin, which
the repeating chains of amino acids held
transports iron in blood.
together by hydrogen bonds. The tertiary
structure is the folding of the secondary
structure held together by the interaction of the
side chains, while the quaternary structure are
protein subunits.

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IMMUNOGLOBULIN dehydrated. The main protein with this function

→ also known as antibodies. These are is albumin.
proteins produced by B-cells (lymphocytes)
PLASMA PROTEINS
in the bone marrow that mediate the humoral
→The plasma proteins are the most
immune response to identify and neutralize
foreign objects. frequently analyzed of all the proteins. The
major measured plasma proteins are divided
IgM, IgA, IgG, IgE, and IgD. into two groups, albumin and globulins.

STRUCTURAL PROTEINS → A typical blood panel will provide four

→ are fibrous proteins that compose the different measurements, the total protein,
structure of cells and tissues such as muscle, albumin, globulins, and the albumin-globulin
tendons, and bone matrix. Examples are (A/G) ratio.
collagen, elastin, and keratin.
PREALBUMIN (TRANSTHYRETIN)
STORAGE PROTEINS → Prealbumin is so named because it migrates
→ are proteins that serve as reserves of metal before albumin in the classic electrophoresis
ions and amino acids that can be released of serum or plasma proteins. It is the transport
and used later without harm occurring to protein for thyroxine and triiodothyronine
cells during the time of storage. An example is (thyroid hormones).
ferritin, which stores iron.
→ It also binds with retinol-binding protein to
Now, iron on its own in the blood could deposit form a complex that transports retinol
in tissues. It needs to be stored within ferritin in (vitamin A).
order for it to not be harmful to the body.
→ Prealbumin is decreased in hepatic damage,
ENERGY SOURCE acute phase inflammatory response, and tissue
→ Plasma proteins can serve as a reserve necrosis.
source of energy for tissues and muscles.
→ It is increased in patients receiving steroids,
OSMOTIC FORCE in alcoholism, and in chronic renal failure.
→ Plasma proteins can function in the
So again, please take note that prealbumin is
distribution of water throughout
decreased in acute phase inflammatory response
compartments in the body. Their colloid osmotic
which means it is a negative acute phase
force, due to their size, does not allow proteins
to cross the capillary membranes. reactant. It is also decreased in hepatic damage
because of course, our proteins are synthesized
→ When the concentration of plasma in the liver. It is increased in chronic renal failure
proteins is significantly decreased, it results in because the kidneys are impaired in degrading
increased levels of interstitial fluid and edema, the protein.
which is often seen in renal disease when
proteinuria occurs. → A low prealbumin level is a sensitive marker
of poor nutritional status. When a diet is
An example would be in proteic syndrome deficient in protein, hepatic synthesis of protein
wherein there is severe proteinuria or protein is reduced with the resulting decrease in the
loss through urinary excretion. The patient level of proteins originating in the liver including
experiences edema or swelling of their limbs and prealbumin, albumin, and beta-globulins.
face, particularly around the eyes, because they
ALBUMIN
have low protein levels. Without these proteins,
→ Albumin is synthesized in the liver from 585
water moves out of the cells and into the
extracellular space, leaving the patient amino acids at the rate of 9-12 grams per day
with no reserve or storage. It is the protein
present in highest concentration in the

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plasma. It buffers pH and is a negative acute GLOBULIN

phase reactant protein. → The globulin group of proteins consists of
alpha-1, alpha-2, beta and gamma. Each
→ Albumin is responsible for nearly 80% of the
fraction consists of a number of different
colloid osmotic pressure of the intravascular proteins with different functions.
fluid which maintains the appropriate fluid
balance in the tissue. alpha-1-antitrypsin
→ It is a glycoprotein mainly synthesized in the
So to reiterate, albumin keeps water inside the
liver. Its most important function is the inhibition
compartments where they are needed, for
of the protease neutrophil elastase which is
example, within cells and inside tissues. Without
released from leukocytes to fight infection, but
albumin to keep water inside, water will flow out
can also destroy alveoli leading to emphysema
of the cells and cause edema or swelling as seen if not controlled by alpha-1-antitrypsin.
in dialysis patients or children with nephrotic
syndrome. It is natural for neutrophils to release neutrophil
elastase during inflammation to fight off
→ Another prime function of albumin is its
infection. However, it can also cause harm by
capacity to bind various substances in the
destroying alveoli in the lungs unless inhibited
blood. There are 4 binding sites on albumin and by alpha-1-antitrypsin.
these have varying specificities for different
substances. Albumin transports thyroid → Mutations in the SERINPINAL gene can
hormones, fat-soluble hormones such as lead to a deficiency of alpha-1-antitrypsin
estrogen and testosterone, iron and fatty protein or an abnormal form of it that cannot
acids. control neutrophil elastase. The abnormal form
can also accumulate in the liver and cause
→ Decreased concentrations may be caused cirrhosis.
by:
→ It is a positive acute phase reactant.
• Malnutrition
Increased levels are seen in inflammatory
• Malabsorption reactions, pregnancy, and contraceptive
• Liver Disease (decreased synthesis) use.
• Renal Disease (loss through urine)
• Protein-losing Enteropathy → Abnormal levels of alpha-1-antitrypsin is
• Absence of Skin Barriers (burns, etc.) marked by the lack of an alpha-1 globulin
• Hypothyroidism band on protein electrophoresis because it is
• Acute disease the major component (approximately 90%),
• Dilution (e.g. polydipsia- excessive of the fraction of serum proteins that migrates
drinking of water, excess IV fluid) immediately following albumin.
• Mutation (e.g. analalbuminemia,
So again, to reiterate, alpha-1-antitrypsin is the
bisalbuminemia)
major component of the alpha-1 globulin band
→ Abnormally high albumin levels are seldom in serum protein electrophoresis. It is the band
clinically important. Increased serum albumin right after albumin.
levels are seen only with dehydration or after
alpha-1-fetoprotein
excessive albumin infusion, which may
→ It is synthesized in the developing embryo
happen during treatment of hypovolemia.
and fetus and then by the parenchymal cells
An example would be in trauma or vehicular of the liver. AFP levels decrease gradually after
accident patients with gaping wounds or loss of birth. It has no known function in normal adults.
limbs, resulting in massive blood and fluid loss. In normal fetuses, AFP binds the hormone
They are given albumin infusion to prevent estradiol.
hypovolemic shock.

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→ Conditions associated with an elevated AFP They usually have overlapping fingers, heart or
level include abdominal wall defects, neural lung abnormalities, clubbed feet, a small
tube defects such as spina bifida and physical size overall, low set ears, and
anencephaly (absence of the major portion of decreased muscle tone.
the brain), and general fetal distress.
alpha-1-acid glycoprotein
(OROSOMUCIOD)
→ It is a major plasma glycoprotein that is
negatively charged even in acid solutions, a
fact that gave it its name. It is produced by the
liver and is a positive acute phase reactant.
There is a strong similarity in the amino acid
sequences between AAG and immunoglobulin.

Fetal distress, also known as non-reassuring → It also serves as a useful diagnostic tool in
fetal status, is a condition during pregnancy or neonates with bacterial infections. It is
labor in which the fetus shows signs of elevated following stress, inflammation, tissue
inadequate oxygenation. Here we have an damage, acute myocardial infarction, trauma,
illustration of a newborn with anencephaly. And pregnancy, pneumonia, rheumatoid arthritis,
here we have a newborn with spina bifida. surgery, and cancer.

→ Low levels of maternal AFP indicate an alpha-1-antichymotrypsin

increased risk for Down syndrome and → It is a member of the serine protease
trisomy 18, while it is elevated in the inhibitor (serpin) family. It inhibits the
presence of twins and neural tube defects. AFP activity of the enzymes cathepsin G,
may also serve as a tumor marker. It is used pancreatic elastase, mast cell kinase, and
in screening chronic liver disease patients for chymotrypsin by cleaving them into a different
hepatocellular carcinoma. shape. It is produced in the liver and is a
positive acute phase reactant.

→ Deficiency of this protein has been

associated with liver disease. Mutations have
been identified in patients with Parkinson's
Disease and Chronic Obstructive
Pulmonary Disease (COPD).

→ It is also associated with the pathogenesis of

Alzheimer's Disease as it is an integral
component of the amyloid deposits in
Alzheimer's disease.
So here we have the key facial characteristics of
Down syndrome. They have an upslanting
palpebral fissure or the area between the open
eyelids.

They have low set small folded ears, a short

neck, a noticeable epicanthal fold, flattened
nasal bridge, and brush-filled spots. Now brush-
filled spots are small, typically white spots
arranged in a ring around the iris. Then we have
trisomy 18 or Edwards syndrome.

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Here we have the symptoms of Parkinson's carcinogenesis. Elevations are seen in

disease. inflammatory disorders (e.g. rheumatoid
arthritis)
They often have astute posture, back rigidity,
flexed elbows and wrists, tremors in the legs, HAPTOGLOBIN
shuffling or short step gait, slightly flexed hip → It is an alpha-2 glycoprotein synthesized
and knees, hand tremors, reduced arm swing, a in the liver. It is a positive acute phase reactant
forward tilt of the trunk, and a masked face. And elevated in ulcerative colitis, acute
here we have chronic obstructive pulmonary rheumatic disease, heart attack, and
disease or COPD. Patients with this disease severe infection.
often have chronic bronchitis and emphysema.
→ Increases are also seen in conditions such as
And here we have an illustration of a patient burns and nephrotic syndrome when large
with Alzheimer's disease. Alzheimer's disease is amounts of fluid and lower molecular weight
a neurodegenerative disease that usually starts proteins have been lost. It has three (3)
slowly and progressively worsens. It is the cause phenotypes found in humans, HP1-1, HP2-1,
of 60-70% of cases of dementia. and HP2-2.

→ Its function is to bind free hemoglobin to

prevent the loss of hemoglobin and its
constituent iron into the urine. Free hemoglobin
is not contained within RBCs.

→ When the haptoglobin and hemoglobin

attach, the reticuloendothelial cells (mainly
in the spleen), remove the haptoglobin-
The most common early symptom is difficulty in hemoglobin complex from the circulation within
remembering recent events. Notice the minutes of its formation. The haptoglobin is
comparison of a healthy brain size and a destroyed, while iron and amino acids are
shrunken brain due to Alzheimer's disease. Now recycled.
Alzheimer's disease begins with the appearance
of a buildup of proteins in the form of amyloid → Haptoglobin testing is used primarily to help
plaques. detect and evaluate hemolytic anemia and to
distinguish it from anemia due to other causes.
So these here are the plaques. Now notice the When the haptoglobin levels are decreased,
comparison between a healthy neuron and a along with an increased reticulocyte count,
dying neuron with tangles. This here is what and a decreased RBC count, hemoglobin,
causes the symptoms in patients with and hematocrit, then it is likely hemolytic
Alzheimer's disease. anemia.
Symptoms often include the inability to Remember that reticulocytes are immature red
communicate, no awareness of recent blood cells in the bone marrow. Their presence
experiences or surroundings, weight loss with in the blood means that the bone marrow is
little interest in eating, seizures, and general releasing them early before they can even
physical decline including dental, skin, and foot mature.The bone marrow does this to
problems. compensate for the fact that there is a
inter-alpha-trypsin inhibitor decreased level of RBCs in the circulation due to
→ Inter-alpha trypsin inhibitors are a family of the anemia. So to visualize this easily, just
serine protease inhibitors (serpin). These remember that haptoglobin decreases because it
molecules have been shown to play a becomes bound to the frehem that came from
particularly important role in inflammation and the RBCs that were hemolyzed.

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 CLINICAL CHEMISTRY I: Introduction and Overview to Clinical Chemistry

→ Haptoglobin has also been used to evaluate Carbamazepine is used to treat seizures and
the degree of intravascular hemolysis that phenobarbital and valproic acid are used to treat
has occurred in transfusion reactions or epilepsy. So if you take any of those
Hemolytic Disease of the Newborn (HDN). medications, your ceruloplasmin levels might be
If the haptoglobin is normal and the increased.
reticulocyte count is increased, then RBC
→ 90% or more of total serum copper is
destruction may be occurring in organs such as
the spleen and liver and not in the circulation. found in ceruloplasmin. The other 10% is bound
to albumin. Ceruloplasmin is primarily ordered
→ If the haptoglobin concentrations are normal along with blood and or urine copper tests to
and the reticulocyte count is not increased, help diagnose Wilson's Disease.
then it is likely that any anemia present is not
due to RBC breakdown → Wilson's Disease is an autosomal recessive
inherited disorder associated with decreased
levels of ceruloplasmin and excess storage
of copper in the liver, brain, and other organs
resulting in hepatic cirrhosis and neurologic
damage. Copper also deposits in the cornea
producing the characteristic Kayser- Fleischer
rings.

So again, since there is a decreased level of

If the haptoglobin is decreased while the ceruloplasmin, the body is unable to properly
reticulocyte count is increased, then the RBC store copper which is why it deposits in the liver,
breakdown occurred in the circulation such as in brain, and other organs resulting in damage.
hemolytic anemia. If haptoglobin is normal while
the reticulocyte count is increased, then the RBC
breakdown occurred in the liver or spleen. So it
is not hemolytic anemia.

If the haptoglobin is normal and the reticulocyte

count is normal or not increased, then the
anemia is not due to RBC breakdown. It could So here we have pictures of patients with kaiser
be a different type of anemia such as IDA or flasher rings.
iron deficiency anemia or SCA, sickle cell anemia
or any other causes of anemia. → Low ceruloplasmin is also seen in
malnutrition, malabsorption, severe liver
→ If haptoglobin levels are decreased without disease, nephrotic syndrome, and Menke's
any signs of hemolytic anemia, then it is syndrome, in which a decreased absorption of
possible that the liver is not producing copper results in a decrease in ceruloplasmin.
adequate amounts of haptoglobin. The early analytic method of ceruloplasmin
CERULOPLASMIN determination was based on its copper
→ It is a copper-containing, alpha-2- oxidase activity.
glycoprotein enzyme that is synthesized in the alpha-2-macroglobulin
liver. It is a positive acute phase reactant. It → It is a large protein synthesized by the liver
may be increased in pregnancy and with the use and is a major component of the alpha-2 band
of estrogen, oral contraceptives, and in protein electrophoresis. It is a tetramer of
medications such as carbamazepine, four identical subunits that inhibits proteases
phenobarbital, and valproic acid. such as trypsin, thrombin, kallikrein, and

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 CLINICAL CHEMISTRY I: Introduction and Overview to Clinical Chemistry

plasmin by means of a bait region that entrap hemosiderin. Transferrin is also decreased in
proteases without completely inactivating them. inflammation.

→ In nephrosis, the levels of serum alpha-2- → Transferrin is abnormally high in Iron-

macroglobulin may increase as much as 10 Deficiency Anemia. An increase of iron
times because its large size aids in its bound to transferrin is found in
retention. It is also increased in diabetes hemochromatosis, a hereditary disorder of
and liver disease. Use of contraceptive iron metabolism, wherein excess iron is
medications and pregnancy increases the deposited in the tissue, especially the liver
serum levels by 20%. and the pancreas. This disorder is associated
with bronze skin, cirrhosis, and diabetes
TRANSFERRIN (SIDEROPHILIN) mellitus.
→ It is a glycoprotein and a negative acute
phase reactant synthesized by the liver. It is the → Total iron binding capacity (TIBC) is
major component of the beta-globulin typically measured along with serum iron to
fraction and appears as a distinct band on evaluate either iron deficiency or iron
High-Resolution Electrophoresis. overload, but it is customary to test for
transferrin when evaluating nutritional
→ Two molecules of ferric iron can bind to
status or liver function. Because it is made in
each molecule of transferrin which binds iron
the liver, transferrin is low in liver disease or
very tightly but reversibly. Its major functions when there is not enough protein in the diet.
are the transport of iron and prevention of
loss of iron through the kidney.

Its binding of iron prevents iron deposition in

tissue during temporary increases in absorbed
iron or free iron.

→ It transports iron to its storage sites where

it is incorporated into apoferritin (which is
another protein) to form ferritin. It also carries
iron to cells, such as bone marrow that By this point, it is important to take note that if
synthesize hemoglobin and other iron-containing a transport protein is bound to its target
compounds. molecule or compound, it will be decreased once
it is analytically measured.
→ Its levels are tested to determine the cause
of anemia, to gauge iron metabolism, and to On the same note, if the transport protein is not
determine the iron-carrying capacity of the bound to its target molecule or compound, its
blood. Low transferrin production can levels will be increased. For example, in iron
impair hemoglobin production and lead to deficiency, serum transferrin and total iron
anemia. binding capacity is increased because the serum
iron is decreased. So transferrin is basically free-
→ A decreased transferrin level can be due to
roaming, that's why it is increased once it is
liver disease, malnutrition, or excessive loss of
measured.
transferrin through the kidneys into urine in
protein-losing disorders such as nephrotic Transferrin saturation is decreased because they
syndrome. cannot be saturated due to the deficiency of
iron. Serum ferritin is also decreased because
→ A deficiency of plasma transferrin may result
adequate levels of iron is needed to synthesize
in the accumulation of iron in apoferritin or in
ferritin. Soluble transferrin receptors are
histocytes, or it may precipitate in tissue as
increased because again, there is a lack of iron
to bind to these receptors.

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 CLINICAL CHEMISTRY I: Introduction and Overview to Clinical Chemistry

On the other hand, in iron overload, the results are synthesized in the liver as single polypeptide
are the exact opposite of that in iron deficiency. chains and circulate in the blood as non-
functional precursors. Complement C3 is the
HEMOPEXIN most abundant, followed by complement C4.
→ The parenchymal cells of the liver synthesize
hemopexin which migrates electrophoretically in FIBRINOGEN
the beta-globulin region and is an acute phase → It is one of the largest proteins in plasma. In
reactant. Its function is to scavenge the heme electrophoresis, fibrinogen is seen as a distinct
released by the turnover of heme proteins such band between the beta and gamma
as hemoglobin which protects the body from the globulins. Its function is to form a fibrin clot
oxidative damage that free heme can cause. when activated by thrombin. Therefore, all
When free heme (ferroprotoporphyrin IX) is fibrinogen is virtually removed in the clotting
formed during the breakdown of hemoglobin, process and is not present in serum.
myoglobin or catalase, it binds to hemopexin in
C-REACTIVE PROTEIN
a 1:1 ratio. The heme-hemopexin complex is
carried to the liver where it is destroyed. → It is synthesized in the liver and is one of the
first acute phase proteins to rise in response to
This is because again, free heme has to be inflammatory disease. CRP received its name
removed from the body because it is toxic. because it precipitates with the C-substance,
a polysaccharide of pneumococci.
→ Increased concentrations of hemopexin are
found in inflammation, diabetes mellitus, → It rises sharply whenever there is tissue
Duchenne-Type Muscular Dystrophy, and some necrosis, whether their damage originates from
malignancies, especially melanomas. Low a pneumococcal infection or some other source.
hemopexin levels are diagnostic of hemolytic CRP bound to bacteria and fungi promotes the
anemia. binding of complement, which facilitates their
uptake by phagocytes. This process is known as
Beta-2-microglobulin opsonization.
→ It is the light chain component of the major
histocompatibility complex (human → Atherosclerosis, in addition to being a
leukocyte antigen or HLA). It is found on the disease of lipid accumulation, also represents a
surface of most nucleated cells and is present in chronic inflammatory process. Elevated levels
high concentrations on lymphocytes. of CRP stimulate the production of tissue factor
that initiates coagulation, activates complement,
→ Elevated serum levels are the result of
and binds to LDL in the atherosclerotic
impaired clearance by the kidneys or plaque.
overproduction of the protein that occurs in a
number of inflammatory diseases such as In other words, since CRP is present in the
rheumatoid arthritis and systemic lupus atherosclerotic lesion, it may actively contribute
erythematosus. to the progression and or instability of the
atherosclerotic plaque.
→ In patients with human immunodeficiency
virus HIV, a high B2M level in the absence IMMUNOGLOBULINS
of renal failure indicates a large lymphocyte → The immunoglobulins (or antibodies) are
turnover rate which suggests that the virus is glycoproteins produced by white blood cells
killing lymphocytes particularly the CD4 positive known as B-cells that grant humoral immunity.
cells (helper T cells) There are five classes of immunoglobulins,
namely the IgG, IgA, IgM, IgD, and IgE. Here
COMPLEMENT
we have illustrations of the basic structure of an
→ The complement system is one of the immunoglobulin.
natural defense mechanisms that protects
the human body from infections. These proteins

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 CLINICAL CHEMISTRY I: Introduction and Overview to Clinical Chemistry

OTHER PROTEINS OF IMPORTANCE

1. FIBRONECTIN
2. ADIPONECTIN
3. BETA-TRACE PROTEIN
4. CROSS-LINKED C-TELOPEPTIDES
5. CRYSTATIN C
6. AMYLOID

Please take note that cross-linked C-telopeptides

are used as a biomarker in the serum to
The Ig monomer is a Y-shaped molecule that
measure the rate of bone turnover.
consists of four polypeptide chains, two identical
heavy chains, and two identical light chains Cystatin C is a protein produced by cells. It is
connected by disulfide bonds. So if you can used to assess kidney function, while amyloids
remember, disulfide bonds are covalent are protein aggregates associated with many
interactions formed between the sulfur atoms of diseases including Alzheimer's disease.
two cysteine amino acid residues.
TOTAL PROTEIN ABNORMALITIES
OTHER PROTEINS OF IMPORTANCE HYPOPROTEINEMIA
MYOGLOBIN → It is when the total protein level is less than
→ It is the primary oxygen-carrying protein the reference interval. It occurs in any condition
found in striated skeletal and cardiac where a negative nitrogen balance exists.
muscle. It can reversibly bind oxygen similarly One cause of a low level of plasma proteins is
to the hemoglobin molecule, but myoglobin excessive loss.
requires a very low oxygen tension to release
→ Plasma proteins can be lost by excretion in
bound oxygen. It is a cardiac biomarker used
in conjunction with troponin. the urine in renal disease, leakage into the
gastrointestinal tract and inflammation of the
→ It is toxic to the kidneys, and in severe digestive system, and the loss of blood in open
muscle injury, levels of myoglobin may rise very wounds, internal bleeding, or extensive burns.
quickly and the kidneys may be damaged by the
→ Another circumstance producing
increased amounts. Renal failure can also
elevate the level of serum myoglobin. hypoproteinemia is decreased intake either
because of malnutrition or through intestinal
CARDIAC TROPONIN malabsorption as seen in SPRU. Without
→ It represents a complex of regulatory adequate dietary intake of proteins, there is a
proteins that include troponin I and troponin deficiency of certain essential amino acids and
T, which are specific to heart muscle. It is the thus, protein synthesis is impaired.
gold standard in diagnosis of acute coronary
syndrome. It has begun to replace CK and CK- HYPERPROTEINEMIA
MB tests because it is more specific to heart → It is an increase in total plasma proteins. It is
injury. not an actual disease state, but it is the result of
an underlying cause which is usually
BRAIN NATRIURETIC PEPTIDE dehydration (relative increase).
(NT-PROBNP)
→ The natriuretic peptides are a family of → In addition to dehydration, hyperproteinemia
structurally-related neurohormones that affect may be the result of excessive production
body fluid homeostasis (through natriuresis primarily of the gamma globulins. The most
and diuresis) and blood pressure (through common disorder is multiple myeloma in
decreased angiotensin II and norepinephrine which the neoplastic plasma cells proliferate in
synthesis), both major components in the the bone marrow.
pathology of congestive heart failure.

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 CLINICAL CHEMISTRY I: Introduction and Overview to Clinical Chemistry

→ It is also seen in patients with

Waldenstrom’s Macroglobulinemia, a rare
type of slow-growing non-Hodgkin lymphoma.

--- END---

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