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 EIGHTH EDITION

CLINICAL BIOCHEMISTRY &

METABOLIC MEDICINE
This page intentionally left blank
 EIGHTH EDITION

CLINICAL BIOCHEMISTRY
& METABOLIC MEDICINE

Professor Martin Andrew Crook BSc MB BS MA PhD FRCPath FRCPI FRCP

Consultant in Chemical Pathology and Metabolic Medicine
Guy’s, St Thomas’ and University Hospital Lewisham, London, UK,
and Visiting Professor, School of Science, University of Greenwich, UK
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742
© 2012 by Taylor & Francis Group, LLC
CRC Press is an imprint of Taylor & Francis Group, an Informa business

No claim to original U.S. Government works

Version Date: 20130412

International Standard Book Number-13: 978-1-4441-4415-4 (eBook - PDF)

This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made to publish reli-
able data and information, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that
may be made. The publishers wish to make clear that any views or opinions expressed in this book by individual editors, authors or contributors are
personal to them and do not necessarily reflect the views/opinions of the publishers. The information or guidance contained in this book is intended
for use by medical, scientific or health-care professionals and is provided strictly as a supplement to the medical or other professional’s own judge-
ment, their knowledge of the patient’s medical history, relevant manufacturer’s instructions and the appropriate best practice guidelines. Because of
the rapid advances in medical science, any information or advice on dosages, procedures or diagnoses should be independently verified. The reader
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 Contents

Preface vii

List of abbreviations viii

1 Requesting laboratory tests and interpreting the results 1

2 Water and sodium 6

3 The kidneys 36

4 Acid–base disturbances 59

5 Potassium 83

6 Calcium, phosphate and magnesium 95

7 The hypothalamus and pituitary gland 116

8 The adrenal cortex 129

9 The reproductive system 146

10 Pregnancy and infertility 157

11 Thyroid function 164

12 Carbohydrate metabolism 176

13 Plasma lipids and lipoproteins 200

14 Nutrition 216

15 Vitamins, trace elements and metals 224

16 The gastrointestinal tract 235

17 Liver disorders and gallstones 252

18 Plasma enzymes in diagnosis (clinical enzymology) 270

19 Proteins in plasma and urine 282

20 Purine and urate metabolism 303

21 Disorders of haem metabolism: iron and the porphyrias 310

22 Cardiovascular disease 325

vi Contents

23 Cerebrospinal, pleural and ascitic fluids 332

24 Metabolic effects of tumours 338

25 Therapeutic drug monitoring and poisoning 347

26 Clinical biochemistry at the extremes of age 358

27 Inborn errors of metabolism 371

28 Genetics and deoxyribonucleic acid-based technology in clinical biochemistry 384

29 Patient sample collection and use of the laboratory 391

30 Point-of-care testing 397

Appendix 1: Units in clinical chemistry 401

Index 403

COMPANION WEBSITE

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www.hodderplus.com/clinicalbiochemistry

The website contains downloadable images from the book as well as self assessment questions.

To access these resources please register on the website using the following access details:

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 Preface

Were it not for the textbook Clinical Chemistry in Diagnosis and Treatment by Joan Zilva and Peter Pannall, I would
not be a chemical pathologist. As a medical student, I was so struck by its clarity, depth and clinical relevance that
I decided that theirs was the medical field I wished to work in.
Over the years, the field of clinical biochemistry has changed radically. Confusingly, there is no consensus
on the name for this field of medicine, which is known variously as clinical chemistry, chemical pathology or
clinical biochemistry, to name but a few. Additionally, the field now overlaps with that of metabolic medicine, a
clinical specialty involved with the management and treatment of patients with disorders of metabolism. Clinical
biochemistry laboratories have become further automated, molecular biology technologies have entered the
diagnostic arena, and chemical pathologists have become more clinically orientated towards running out-patient
clinics for a variety of biochemical disturbances. This book aims to address these new changes. Indeed, it is difficult
to imagine a branch of medicine that does not at some time require clinical biochemistry tests, which may not be
too surprising, given the fact that every body cell is composed of chemicals!
Unfortunately, there have been some difficulties in recent times, with a relative shortage of graduates entering
the specialty, which has not been helped by some people’s attitude that clinical biochemistry is merely a laboratory
factory churning out results that anyone can interpret. There are also concerns that medical student clinical
biochemistry teaching may become ‘diluted’ as part of an expanding curriculum. It is hoped that this book will
excite a new generation to enter this fascinating and essential field, as well as benefit patients as their doctors learn
more about their biochemical and metabolic problems.
I am most grateful to Dr Sethsiri Wijeratne, Dr Alam Garrib (particularly for molecular biology expertise) and
Dr Paul Eldridge for constructive criticism of the text. I am also grateful to Professor Philip Mayne for his earlier
contributions and the anonymous medical student reviewer(s) who commented on the text. The book has also
greatly benefited from the wise, helpful and experienced input of Dr Andrew Day – many thanks. Although every
effort has been made to avoid inaccuracies and errors, it is almost inevitable that some may still be present, and
feedback from readers is therefore welcome.
Martin Crook
London, 2012

Disclaimer The publishers and author accept no responsibility for errors in the text or misuse of the material
presented. Drugs and their doses should be checked with a pharmacy, and the investigation protocols with an
appropriate clinical laboratory. Dynamic test protocols should be checked with an accredited clinical investigation
unit and may require different instructions in the elderly, children and the obese.
 List of abbreviations

ABC1 adenosine triphosphate-binding cassette CA carbohydrate antigen

protein 1 CaE calcium excreted per litre of glomerular
ACE angiotensin-converting enzyme filtrate
ACP acid phosphatase CAH congenital adrenal hyperplasia
ACR albumin to creatinine ratio cAMP cyclic adenosine monophosphate
ACTH adrenocorticotrophic hormone CaSR calcium-sensing receptor
(corticotrophin) CAT computerized axial tomography
ADH antidiuretic hormone (arginine CBG cortisol-binding globulin (transcortin)
vasopressin) CD carbonate dehydratase (carbonic
A&E accident and emergency (department) anhydrase)
AFP a-fetoprotein CEA carcinoembryonic antigen
AIDS acquired immunodeficiency syndrome CETP cholesterol ester transfer protein
AIS autoimmune insulin syndrome CK creatine kinase
AKI acute kidney injury CKD chronic kidney disease
ALA 5-aminolaevulinic acid CNP C-type natriuretic peptide
ALP alkaline phosphatase CNS central nervous system
ALT alanine aminotransferase (also known CoA coenzyme A
as glutamate pyruvate aminotransferase, COPD chronic obstructive pulmonary disease
GPT) CRH corticotrophin-releasing hormone
AMC arm muscle circumference CRP C-reactive protein
ANA antinuclear antibody CSF cerebrospinal fluid
ANCA antineutrophil cytoplasmic antibody CT computerized tomography
ANP atrial natriuretic peptide CV coefficient of variation
APA aldosterone-producing adenoma Cys C cystatin C
apo apolipoprotein
APRT adenine phosphoribosyl transferase 2,3-DPG 2,3-diphosphoglycerate
APUD amine precursor uptake and DDAVP 1-desamino-8-D-arginine vasopressin
decarboxylation (desmopressin acetate)
ARA angiotensin II receptor antagonist DHEA dehydroepiandrosterone
ARB angiotensin II receptor blocker DHEAS dehydroepiandrosterone sulphate
ARMS amplification refractory mutation DIT di-iodotyrosine
system DNA deoxyribonucleic acid
AST aspartate aminotransferase (also DPP-4 dipeptidyl peptidase-4
known as glutamate oxaloacetate DVT deep vein thrombosis
aminotransferase, GOT)
ATPase adenosine triphosphatase ECF extracellular fluid
ATP adenosine triphosphate ECG electrocardiogram
EDTA ethylenediamine tetra-acetic acid
BJP Bence Jones protein eGFR estimated glomerular filtration rate
BMD bone mineral density ENA extractable nuclear antigen
BMI body mass index ENT ear, nose and throat (department)
BMR basal metabolic rate ERCP endoscopic retrograde
BNP brain natriuretic peptide cholangiopancreatography
BPH benign prostatic hyperplasia ESR erythrocyte sedimentation rate
 List of abbreviations ix

EUS endoscopic ultrasonography 5-HT hydroxytryptamine (serotonin)

5-HTP hydroxytryptophan
FAD flavine adenine dinucleotide HVA homovanillic acid
FCH familial combined hyperlipidaemia
FDH familial dysalbuminaemic IAH idiopathic adrenal hyperplasia
hyperthyroxinaemia IDL intermediate-density lipoprotein
FENa% fractional excretion of sodium IDMS isotope dilution mass spectrometry
FEPi% fractional excretion of phosphate IEM inborn errors of metabolism
FH familial hypercholesterolaemia IFG impaired fasting glucose
FMN flavine mononucleotide IFN interferon
FSH follicle-stimulating hormone Ig immunoglobulin
fT4 free T4 IGF insulin-like growth factor
fT3 free T3 IGT impaired glucose tolerance
IL interleukin
GAD glutamic decarboxylase INR international normalized ratio
GDM gestational diabetes mellitus
GFR glomerular filtration rate LADA latent autoimmune diabetes of adults
GGT g-glutamyl transferase LCAT lecithin–cholesterol acyltransferase
GH growth hormone LDH lactate dehydrogenase
GHRH growth hormone-releasing hormone LDL low-density lipoprotein
GIP gastric inhibitory peptide LH luteinizing hormone
GLP-1 glucagon-like peptide 1 LR likelihood ratio
GnRH gonadotrophin-releasing hormone
G6P glucose-6-phosphate MCADD medium-chain acyl coenzyme A
G6PD glucose-6-phosphate dehydrogenase dehydrogenase deficiency
GRA glucocorticoid remediable aldosteronism MCH mean corpuscular haemoglobin
MCV mean corpuscular volume
HAV hepatitis A virus MDRD modification of diet in renal disease
Hb haemoglobin (formula)
HbA1c glycated haemoglobin MEGX monoethylglycinexylidide
HBsAg viral surface antigen MEN multiple endocrine neoplasia
HBD hydroxybutyrate dehydrogenase MGUS monoclonal gammopathy of
HBV hepatitis B virus undetermined significance
hCG human chorionic gonadotrophin MIBG metaiodobenzylguanidine
HCV hepatitis C virus MIT mono-iodotyrosine
HDL high-density lipoprotein MODY maturity-onset diabetes of the young
HELP heparin extracorporeal low-density MPS mucopolysaccharidosis
lipoprotein precipitation MRCP magnetic resonance
HFE human haemochromatosis protein cholangiopancreatography
HGPRT hypoxanthine–guanine phosphoribosyl MRI magnetic resonance imaging
transferase mRNA messenger ribonucleic acid
5-HIAA 5-hydroxyindole acetic acid MSH melanocyte-stimulating hormone
HIV human immunodeficiency virus mtDNA mitochondrial DNA
HLA human leucocyte antigen MTHFR methylenetetrahydrofolate reductase
HMG-CoA 3-hydroxy-3-methyl glutaryl coenzyme A
HMMA 4-hydroxy-3-methoxymandelic acid NAD nicotinamide adenine dinucleotide
HNF hepatocyte nuclear factor NADP nicotinamide adenine dinucleotide
HONK hyperosmolal non-ketotic (coma) phosphate
HRT hormone replacement therapy NAFLD non-alcoholic fatty liver disease
hs-CRP high-sensitivity C-reactive protein NAG N-acetyl-b-D-glucosaminidase
x List of abbreviations

NASH non-alcoholic steatotic hepatitis SCID severe combined immunodeficiency

NEFA non-esterified fatty acid SD standard deviation
NGAL neutrophil gelatinase-associated lipocalin SHBG sex-hormone-binding globulin
NHS National Health Service SIADH syndrome of inappropriate antidiuretic
NICTH non-islet cell tumour hypoglycaemia hormone secretion
NP natriuretic peptide SLE systemic lupus erythematosus
NSAID non-steroidal anti-inflammatory drug STEMI ST-segment elevation myocardial
NSTEMI non-ST segment elevation myocardial infarction
infarction
T3 tri-iodothyronine
OGTT oral glucose tolerance test T4 thyroxine
OTC ornithine transcarbamylase TBG thyroxine-binding globulin
TBW total body water
PABA para-amino benzoic acid TCA tricarboxylic acid
PBG porphobilinogen TfR transferrin receptor
PCR polymerase chain reaction TIBC total iron-binding capacity
PEG polyethylene glycol TNF tumour necrosis factor
PH primary hyperaldosteronism TPO thyroid peroxidase
PI protease inhibitor TPMT thiopurine methyltransferase
PIVKA proteins induced by vitamin K absence TRH thyrotrophin-releasing hormone
PKU phenylketonuria TSH thyroid-stimulating hormone
PNI prognostic nutritional index TSI thyroid-stimulating immunoglobulin
POCT point-of-care testing TTKG transtubular potassium gradient
PPAR peroxisome proliferator-activated receptor
PRPP phosphoribosyl pyrophosphate UGT uridine glucuronyl transferase
PSA prostate-specific antigen UIBC unsaturated iron-binding capacity
PTH parathyroid hormone URL upper reference limit
PTHRP parathyroid hormone-related protein
VIP vasoactive intestinal polypeptide
RBP retinol-binding protein VLCFA very long-chain fatty acid
RDS respiratory distress syndrome VLDL very low-density lipoprotein
RFLP restriction fragment length VDBP vitamin D-binding protein
polymorphism VDR vitamin D receptor
RNA ribonucleic acid
ROC receiver operating characteristic (curve) WHO World Health Organization
RRT renal replacement therapy
 1 Requesting laboratory tests and
interpreting the results

Requesting laboratory tests 1 Interpreting results 2

How often should I investigate the patient? 1 Is the abnormality of diagnostic value? 3
When is a laboratory investigation ‘urgent’? 1 Diagnostic performance 4

REQUESTING LABORATORY TESTS rapidly in patients given large doses of diuretics and
There are many laboratory tests available to the clinician. these alterations may indicate the need to instigate or
Correctly used, these may provide useful information, change treatment (see Chapter 5).
but, if used inappropriately, they are at best useless and Laboratory investigations are very rarely needed
at worst misleading and dangerous. more than once daily, except in some patients receiving
In general, laboratory investigations are used: intensive therapy. If they are, only those that are
● to help diagnosis or, when indicated, to screen for essential should be repeated.
metabolic disease, WHEN IS A LABORATORY
● to monitor treatment or detect complications, INVESTIGATION ‘URGENT’?
● occasionally for medicolegal reasons or, with due
The main reason for asking for an investigation to be
permission from the patient, for research.
performed ‘urgently’ is that an early answer will alter
Overinvestigation of the patient may be harmful, the patient’s clinical management. This is rarely the
causing unnecessary discomfort or inconvenience, case and laboratory staff should be consulted and the
delaying treatment or using resources that might be sample ‘flagged’ as clearly urgent if the test is required
more usefully spent on other aspects of patient care. immediately. Laboratories often use large analysers
Before requesting an investigation, clinicians should capable of assaying hundreds of samples per day
consider whether its result would influence their clinical (Fig. 1.1). Point-of-care testing can shorten result
management of the patient. turnaround time and is discussed in Chapter 30.
Close liaison with laboratory staff is essential; they
may be able to help determine the best and quickest
procedure for investigation, interpret results and
discover reasons for anomalous findings.

HOW OFTEN SHOULD I INVESTIGATE

THE PATIENT?
This depends on the following:
● How quickly numerically significant changes are
likely to occur: for example, concentrations of the
main plasma protein fractions are unlikely to change
significantly in less than a week (see Chapter 19),
similarly for plasma thyroid-stimulating hormone
(TSH; see Chapter 11). See also Chapter 3.
● Whether a change, even if numerically significant, will
alter treatment: for example, plasma transaminase
activities may alter within 24 h in the course of acute
hepatitis, but, once the diagnosis has been made, this Figure 1.1 A laboratory analyser used to assay
is unlikely to affect treatment (see Chapter 17). By hundreds of blood samples in a day. Reproduced with
contrast, plasma potassium concentrations may alter kind permission of Radiometer Limited.
2 Requesting laboratory tests and interpreting the results

Laboratories usually have ‘panic limits’, when Test reference ranges

highly abnormal test results indicate a potentially life- By convention, a reference (‘normal’) range (or interval)
threatening condition that necessitates contacting the usually includes 95 per cent of the test results obtained
relevant medical staff immediately. To do so, laboratory from a healthy and sometimes age- and sex-defined
staff must have accurate information about the location population. For the majority of tests, the individual’s
of the patient and the person to notify. results for any constituent are distributed around
INTERPRETING RESULTS this mean in a ‘normal’ (Gaussian) distribution, the
95 per cent limits being about two standard deviations
When interpreting laboratory results, the clinician
from the mean. For other tests, the reference distribution
should ask the following questions:
may be skewed, either to the right or to the left, around
● Is the result the correct one for the patient? the population median. Remember that 2.5 per cent of
● Does the result fit with the clinical findings? the results at either end will be outside the reference
Remember to treat the patient and not the range; such results are not necessarily abnormal for that
‘laboratory numbers’. individual. All that can be said with certainty is that
● If it is the first time the test has been performed the probability that a result is abnormal increases the
on this patient, is the result normal when the further it is from the mean or median until, eventually,
appropriate reference range is taken into account? this probability approaches 100 per cent. Furthermore,
● If the result is abnormal, is the abnormality of a normal result does not necessarily exclude the disease
diagnostic significance or is it a non-specific that is being sought; a test result within the population
finding? reference range may be abnormal for that individual.
● If it is one of a series of results, has there been Very few biochemical tests clearly separate a ‘normal’
a change and, if so, is this change clinically population from an ‘abnormal’ population. For
significant? most there is a range of values in which ‘normal’ and
‘abnormal’ overlap (Fig. 1.2), the extent of the overlap
Abnormal results, particularly if unexpected and
differing for individual tests. There is a 5 per cent chance
indicating the need for clinical intervention, are best
that one result will fall outside the reference range, and
repeated.
with 20 tests a 64 per cent chance, i.e. the more tests
done, the more likely it is that one will be statistically
CASE 1 abnormal.
No result of any investigation should be interpreted
A blood sample from a 4-year-old boy with without consulting the reference range issued by the
abdominal pain was sent to the laboratory from an
accident and emergency department. Some of the
results were as follows: 160

Plasma 140
Bilirubin 14 µmol/L (< 20) 120
Alanine transaminase 14 U/L (< 42)
Number of subjects

Alkaline phosphatase 326 U/L (< 250) 100

Albumin 40 g/L (35–45) 80
g-Glutamyl transferase 14 U/L (< 55) ‘Normal’
Albumin-adjusted calcium 2.34 mmol/L (2.15–2.55) 60 subjects
Overlap between
DISCUSSION 40 ‘normal’ and ‘ill’
The patient’s age was not given on the request form
20
and the laboratory computer system ‘automatically’ ‘Ill subjects’
used the reference ranges for adults. The plasma
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
alkaline phosphatase activity is raised if compared
Arbitrary units
with the adult reference range, but in fact is within
‘normal limits’ for a child of 4 years (60–425). See Figure 1.2 Theoretical distribution of values for
‘normal’ and ‘abnormal’ subjects, showing overlap at
also Chapters 6 and 18.
the upper end of the reference range.
 Is the abnormality of diagnostic value? 3

laboratory carrying out the assay. Some analytes have the patient fasting. This is not usually possible, and
risk limits for treatment, such as plasma glucose (see these variations should be taken into account when
Chapter 12), or target or therapeutic limits, such as serial results are interpreted.
plasma cholesterol (see Chapter 13). Some constituents vary monthly, especially in
Various non-pathological factors may affect the women during the menstrual cycle. These variations
results of investigations, the following being some of can be very marked, as in the results of sex hormone
the more important ones. assays, for example plasma oestradiol, which can only be
interpreted if the stage of the menstrual cycle is known;
Between-individual differences
plasma iron may fall to very low concentrations just
Physiological factors such as the following affect the before the onset of menstruation. Other constituents
interpretation of results. may also vary seasonally. For example, vitamin D
concentrations may be highest in the summer months.
Age-related differences
Some of these changes, such as the relation between
These include, for example, bilirubin in the neonate plasma glucose and meals, have obvious causes.
(see Chapter 26) and plasma alkaline phosphatase
activity, which is higher in children and the elderly (see Random
Chapter 18). Day-to-day variations, for example in plasma iron
concentrations, can be very large and may swamp regular
Sex-related differences
cycles. The causes of these are not clear, but they should be
Examples of sex-related differences include plasma allowed for when serial results are interpreted – for example
urate, which is higher in males, and high-density the effect of ‘stress’ on plasma cortisol concentrations.
lipoprotein cholesterol, which is higher in pre- The time of meals affects plasma glucose
menopausal women than in men (see Chapters 13 and concentrations, and therefore correct interpretation
20). Obviously, sex hormone concentrations also differ is often only possible if the blood is taken when the
between the sexes (see Chapter 9). patient is fasting or at a set time after a standard dose of
glucose (see Chapter 12).
Ethnic differences
These may occur because of either racial or environmental Methodological differences between
laboratories
factors, for example plasma creatine kinase may be higher
in black than in white people (see Chapter 18). It has been pointed out that, even if the same method
is used throughout a particular laboratory, it is
Within-individual variations difficult to define normality clearly. Interpretation
There are biological variations of both plasma may sometimes be even more difficult if the results
concentrations and urinary excretion rates of many obtained in different laboratories, using different
constituents, and test results may be incorrectly analytical methods, are compared. Agreement between
interpreted if this is not taken into consideration. laboratories is close for many constituents partly due
Biological variations may be regular or random. to improved standardization procedures and because
many laboratories belong to external quality control
Regular schemes. However, for others, such as plasma enzymes,
Such changes occur throughout the 24-h period different methods may give different results. For various
(circadian or diurnal rhythms, like those of body technical reasons, the results would still vary unless the
temperature) or throughout the month. The daily substrate, pH and all the other variables were the same.
(circadian) variation of plasma cortisol is of diagnostic
value, but, superimposed on this regular variation, IS THE ABNORMALITY OF DIAGNOSTIC
‘stress’ will cause an acute rise (see Chapter 8). Plasma VALUE?
iron concentrations may fall by 50 per cent between Relation between plasma and cellular
morning and evening (see Chapter 21). To eliminate concentrations
the unwanted effect of circadian variations, blood Intracellular constituents are not easily sampled,
should ideally always be taken at the same time of day, and plasma concentrations do not always reflect the
preferably in the early morning and, if indicated, with situation in the cells; this is particularly true for those
4 Requesting laboratory tests and interpreting the results

constituents, such as potassium and phosphate, that DIAGNOSTIC PERFORMANCE

are at much higher concentrations intracellularly Before one can interpret day-to-day changes in results
than extracellularly. A normal, or even high, plasma and decide whether the patient’s biochemical state
potassium concentration may be associated with has altered, one must know the degree of variation
cellular depletion if equilibrium across cell membranes to be expected in the results derived from a normal
is abnormal, such as in diabetic ketoacidosis. Analyte population. We have already discussed intraindividual
concentrations may differ between plasma (the (same person) analyte variation. However, there is also
aqueous phase of anticoagulated blood) and serum (the unavoidable analytical variation.
aqueous phase of clotted blood). The concentration
of potassium, for example, is higher in serum than in
CASE 3
plasma samples because of leakage from cells during
clotting, and the total protein concentration is lower in One hundred patients with chest pain were screened
serum than in plasma because the protein fibrinogen is with a new biochemical test that showed 80 to be
removed during the clotting process. positive for chest pain. What is the test’s sensitivity?
Answer: 80/100 ¥ 100% = 80%
Non-specific abnormalities
The same test was used on 100 patients without chest
The concentrations of all protein fractions, including pain, and 95 had a negative screening result. What is
immunoglobulins, and of protein-bound substances the test’s specificity?
may fall by as much as 15 per cent after as little as 30 min Answer: 95/100 ¥ 100% = 95%
recumbency, owing to fluid redistribution in the body.
DISCUSSION
This may account, at least in part, for the low plasma
Sensitivity is true-positive rate per total affected.
albumin concentrations found in even quite minor
Specificity is true-negative rate per total unaffected.
illnesses. In-patients often have blood taken early in the
morning, while recumbent, and plasma concentrations
of protein and protein-bound substances tend to be
Reproducibility of laboratory estimations
lower than in out-patients (see Chapter 19).
Most laboratory estimations should give results that
are reproducible to well within 5 per cent; some, such
as those for sodium and calcium, should be even more
CASE 2 precise, but the variability of some hormone assays,
for example, may be greater. Small changes in results
A 54-year-old Nigerian man was seen in an accident
produced by relatively imprecise methods are not likely
and emergency department because of chest pain.
to be clinically significant.
His electrocardiogram (ECG) was normal. The
Imprecision is the term used to describe the random
following results were returned from the laboratory,
changes that reduce the agreement between replicate
6 h after his chest pain started:
assay measurements. This can be considered in terms of
Plasma the within-assay precision, which is the assay variability
Creatine kinase 498 U/L (< 250) when the same material is assayed repeatedly within
Troponin T 10 pg/L (< 20) the same assay batch, or day-to-day precision, which
DISCUSSION is the variability when the same material is assayed on
The raised plasma creatine kinase activity suggested an different days.
acute myocardial infarction (see also Chapters 18 and The assay coefficient of variation (CV) is used
22). The patient was, however, subsequently found not to express imprecision and can be calculated by the
to have had a myocardial infarction (confirmed by a following equation:
normal troponin T result) and the raised plasma creatine standard deviation of the assay
kinase activity was thought to be due to his racial origin. CV% = ¥ 100%
mean of the assay results
(The reference range of < 250 U/L was based on that (1.1)
of the predominantly white UK population; normal
This should be as small as possible for each assay, and
plasma creatine kinase activity may be two to three
can be expressed as the intra-assay CV when describing
times higher in black than in white people.)
the imprecision within a single run or batch.
 Diagnostic performance 5

Test sensitivity and specificity 1

Diagnostic sensitivity is a measure of the frequency of a A

B
test being positive when a particular disease is present, C
that is, the percentage of true-positive (TP) results.
Diagnostic specificity is a measure of the frequency of

Sensitivity
a test being negative when a certain disease is absent,
that is, the percentage of true-negative (TN) results.
Ideally, a test would have 100 per cent specificity and
100 per cent sensitivity.
The usefulness of tests can be expressed visually as
receiver operating characteristic (ROC) curves (Fig. 1.3).
Unfortunately, in population screening, some 0
subjects with a disorder may have a negative test (false- 0 1
negative, FN); conversely, some subjects without the 1 – Specificity
condition in question will show an abnormal or positive Figure 1.3 Receiver operating characteristic (ROC)
result (false-positive, FP). curve. The greater the area under the curve, the more
The predictive value of a negative result is the percentage useful the diagnostic test. Test B is less useful than
of all negative results that are true negatives, that is, the test A, which has greater sensitivity and specificity. C
frequency of subjects without the disorder in all subjects depicts chance performance (area under the curve 0.5).
with negative test results. A high negative predictive
value is important in screening programmes if affected specificity decline. Conversely, if a diagnostic test has its
individuals are not to be missed. This can be expressed as: cut-off or action limit set too high, fewer falsely positive
TN individuals will be encompassed, but more individuals
¥ 100% (1.2)
TN + FN will be falsely defined as negative, that is, its sensitivity
The predictive value of a positive result is the will decrease and its specificity will increase.
percentage of all positive results that are true positives: Likelihood ratios of laboratory tests
in other words, the proportion of screening tests that
Some may find predictive values confusing, and the
are correct. A high positive predictive value is important
likelihood ratio (LR) may be preferable. This can be
to minimize the number of false-positive individuals
defined as the statistical odds of a factor occurring
being treated unnecessarily. This can be expressed as:
in one individual with a disorder compared with it
TP occurring in an individual without that disorder.
¥ 100% (1.3)
TP + FP The LR for a negative test is expressed as:
The overall efficiency of a test is the percentage of
1 – sensitivity
patients correctly classified by the test. This should be (1.5)
specificity
as high as possible and can be expressed as:
The LR for a positive test is expressed as:
TP + TN
¥ 100% (1.4) sensitivity (1.6)
TP + FP + TN + FN
If the cut-off, or action, limit of a diagnostic test 1 – specificity
is set too low, more falsely positive individuals will The greater the LR, the more clinically useful is the
be included, and its sensitivity will increase and its test in question.

SUMMARY
● Careful thought is required when it comes to ● The laboratory reference range should be consulted
requesting and interpreting clinical biochemistry when interpreting biochemical results, and results
tests. should be interpreted in the light of the clinical findings.
● Communication with the laboratory is essential to ● Just because a result is ‘abnormal’ does not mean
ensure optimal interpretation of results and patient that the patient has an illness; conversely, a ‘normal’
management. result does not exclude a disease process.
 2 Water and sodium

Total sodium and water balance 6 Urinary sodium estimation 13

Control of water and sodium balance 7 Disturbances of water and sodium metabolism 15
Distribution of water and sodium in the body 9

It is essential to understand the linked homeostatic mainly in the ECF (Table 2.2). Water and electrolyte
mechanisms controlling water and sodium balance intake usually balance output in urine, faeces, sweat
when interpreting the plasma sodium concentration and expired air.
and managing the clinically common disturbances of
Water and sodium intake
water and sodium balance. This is of major importance
in deciding on the composition and amount, if any, of The daily water and sodium intakes are variable, but in
intravenous fluid to give. It must also be remembered an adult amount to about 1.5–2 L and 60–150 mmol,
that plasma results may be affected by such intravenous respectively.
therapy, and can be dangerously misunderstood. Water and sodium output
Water is an essential body constituent, and Kidneys and gastrointestinal tract
homeostatic processes are important to ensure that
the total water balance is maintained within narrow The kidneys and intestine deal with water and electrolytes
limits, and the distribution of water among the in a similar way. Net loss through both organs depends
vascular, interstitial and intracellular compartments is on the balance between the volume filtered proximally
maintained. This depends on hydrostatic and osmotic Table 2.1 Approximate contributions of solutes to
forces acting across cell membranes. plasma osmolality
Sodium is the most abundant extracellular cation
and, with its associated anions, accounts for most of Osmolality (mmol/kg) Total (%)
the osmotic activity of the extracellular fluid (ECF); it Sodium and its anions 270 92
is important in determining water distribution across Potassium and its anions 7
cell membranes. Calcium (ionized) and its anions 3
Osmotic activity depends on concentration, and
Magnesium and its anions 1
therefore on the relative amounts of sodium and water 8
Urea 5
in the ECF compartment, rather than on the absolute
quantity of either constituent. An imbalance may cause Glucose 5
hyponatraemia (low plasma sodium concentration) or Protein 1 (approx.)
hypernatraemia (high plasma sodium concentration), Total 292 (approx.)
and therefore changes in osmolality. If water and sodium
are lost or gained in equivalent amounts, the plasma Table 2.2 The approximate volumes in different body
sodium, and therefore the osmolal concentration, is compartments through which water is distributed in a
unchanged; symptoms are then due to extracellular 70-kg adult
volume depletion or overloading (Table 2.1). As the
metabolism of sodium is so inextricably related to that Volume (L)
of water, the two are discussed together in this chapter. Intracellular fluid compartment 24
Extracellular fluid compartment 18
TOTAL SODIUM AND WATER BALANCE
Interstitial (13)
In a 70-kg man, the total body water (TBW) is about
Intravascular (blood volume) (5)
42 L and contributes about 60 per cent of the total body
weight; there are approximately 3000 mmol of sodium, Total body water 42
 Control of water and sodium balance 7

and that reabsorbed more distally. Any factor affecting Control of antidiuretic hormone secretion
either passive filtration or epithelial cellular function The secretion of ADH is stimulated by the flow of
may disturb this balance. water out of cerebral cells caused by a relatively high
Approximately 200 L of water and 30 000 mmol of extracellular osmolality. If intracellular osmolality
sodium are filtered by the kidneys each day; a further is unchanged, an extracellular increase of only
10 L of water and 1500 mmol of sodium enter the 2 per cent quadruples ADH output; an equivalent
intestinal lumen. The whole of the extracellular water fall almost completely inhibits it. This represents a
and sodium could be lost by passive filtration in little change in plasma sodium concentration of only about
more than an hour, but under normal circumstances 3 mmol/L. In more chronic changes, when the osmotic
about 99 per cent is reabsorbed. Consequently, the gradient has been minimized by solute redistribution,
net daily losses amount to about 1.5–2 L of water and there may be little or no effect. In addition, stretch
100 mmol of sodium in the urine, and 100 mL and receptors in the left atrium and baroreceptors in the
15 mmol, respectively, in the faeces. aortic arch and carotid sinus influence ADH secretion
Fine adjustment of the relative amounts of water in response to the low intravascular pressure of severe
and sodium excretion occurs in the distal nephron and hypovolaemia, stimulating ADH release. The stress
the large intestine, often under hormonal control. The due to, for example, nausea, vomiting and pain may
effects of antidiuretic hormone (ADH) or vasopressin also increase ADH secretion. Inhibition of ADH
and the mineralocorticoid hormone aldosterone on secretion occurs if the extracellular osmolality falls,
the kidney are the most important physiologically, for whatever reason.
although natriuretic peptides are also important.
Actions of antidiuretic hormone
Sweat and expired air Antidiuretic hormone, by regulating aquaporin
About 1 L of water is lost daily in sweat and expired 2, enhances water reabsorption in excess of solute
air, and less than 30 mmol of sodium a day is lost in from the collecting ducts of the kidney and so
sweat. The volume of sweat is primarily controlled dilutes the extracellular osmolality. Aquaporins are
by skin temperature, although ADH and aldosterone cell membrane proteins acting as water channels
have some effect on its composition. Water loss in that regulate water flow. When ADH secretion is a
expired air depends on the respiratory rate. Normally, response to a high extracellular osmolality with the
losses in sweat and expired air are rapidly corrected by danger of cell dehydration, this is an appropriate
changes in renal and intestinal loss. However, neither response. However, if its secretion is in response to
of these losses can be controlled to meet sodium and a low circulating volume alone, it is inappropriate to
water requirements, and thus they may contribute the osmolality. The retained water is then distributed
considerably to abnormal balance when homeostatic throughout the TBW space, entering cells along the
mechanisms fail. osmotic gradient; the correction of extracellular
depletion with water alone is thus relatively inefficient
CONTROL OF WATER AND SODIUM
in correcting hypovolaemia. Plasma osmolality
BALANCE
normally varies by less than 1–2 per cent, despite
Control of water balance
great variation in water intake, which is largely due to
Both the intake and loss of water are controlled by the action of ADH.
osmotic gradients across cell membranes in the brain’s In some circumstances, the action of ADH is
hypothalamic osmoreceptor centres. These centres, opposed by other factors. For example, during an
which are closely related anatomically, control thirst osmotic diuresis the urine, although not hypo-osmolal,
and the secretion of ADH. contains more water than sodium. Patients with severe
hyperglycaemia, as in poorly controlled diabetes
Antidiuretic hormone (arginine vasopressin)
mellitus, may show an osmotic diuresis.
Antidiuretic hormone is a polypeptide with a half-life
of about 20 min that is synthesized in the supraoptic Control of sodium balance
and paraventricular nuclei of the hypothalamus and, The major factors controlling sodium balance are renal
after transport down the pituitary stalk, is secreted blood flow and aldosterone. This hormone controls
from the posterior pituitary gland (see Chapter 7). loss of sodium from the distal tubule and colon.
8 Water and sodium

Aldosterone and the distal convoluted tubule. Renin is derived from

Aldosterone, a mineralocorticoid hormone, is secreted prorenin by proteolytic action, and secretion increases
by the zona glomerulosa of the adrenal cortex (see in response to a reduction in renal artery blood flow,
Chapter 8). It affects sodium–potassium and sodium– possibly mediated by changes in the mean pressure in the
hydrogen ion exchange across all cell membranes. Its afferent arterioles, and b-adrenergic stimulation. Renin
main effect is on renal tubular cells, but it also affects splits a decapeptide (angiotensin I) from a circulating a2-
loss in faeces, sweat and saliva. Aldosterone stimulates globulin known as renin substrate. Another proteolytic
sodium reabsorption from the lumen of the distal enzyme, angiotensin-converting enzyme (ACE), which
renal tubule in exchange for either potassium or is located predominantly in the lungs but is also present
hydrogen ions (Fig. 2.1). The net result is the retention in other tissues such as the kidneys, splits off a further
of more sodium than water, and the loss of potassium two amino acid residues. This is the enzyme that ACE
and hydrogen ions. If the circulating aldosterone inhibitors (used to treat hypertension and congestive
concentration is high and tubular function is normal, cardiac failure) act on. The remaining octapeptide,
the urinary sodium concentration is low. angiotensin II, has a number of important actions:
Many factors are involved in the feedback control of ● It acts directly on capillary walls, causing
aldosterone secretion. These include local electrolyte vasoconstriction, and so probably helps to maintain
concentrations, such as that of potassium in the adrenal blood pressure and alter the glomerular filtration rate
gland, but they are probably of less physiological (GFR). Vasoconstriction may raise the blood pressure
and clinical importance than the effect of the renin– before the circulating volume can be restored.
angiotensin system. ● It stimulates the cells of the zona glomerulosa to
synthesize and secrete aldosterone.
The renin–angiotensin system
● It stimulates the thirst centre and so promotes oral
Renin is an aspartyl protease secreted by the fluid intake.
juxtaglomerular apparatus, a cellular complex adjacent
to the renal glomeruli, lying between the afferent arteriole Poor renal blood flow is often associated with an
inadequate systemic blood pressure. The release of
Glomerulus renin results in the production of angiotensin II, which
B– Na+ tends to correct this by causing aldosterone release,
which stimulates sodium and water retention and hence
restores the circulating volume. Thus, aldosterone
secretion responds, via renin, to a reduction in renal
blood flow. Sodium excretion is not directly related
to total body sodium content or to plasma sodium
concentration.
B– Na+ Na+ Na+
Aldosterone Natriuretic peptides
H+ HCO3–
H+ A peptide hormone (or hormones) secreted from
K+
Renal the right atrial or ventricular wall in response to the
tubular stimulation of stretch receptors may cause high sodium
lumen H2CO3
HB excretion (natriuresis) by increasing the GFR and by
inhibiting renin and aldosterone secretion. However,
CD
the importance of this hormone (or hormones) in
CO2 the physiological control of sodium excretion and in
H2O pathological states has not yet been fully elucidated,
although it is important in the pathophysiology of
Renal tubular cell
congestive cardiac failure (see Chapter 22).
Figure 2.1 The action of aldosterone on the
Monitoring fluid balance
reabsorption of Na+ in exchange for either K+ or H+
from the distal renal tubules. See text for details. CD, The most important factor in assessing changes in
carbonate dehydratase; B–, associated anion. day-to-day fluid balance is accurate records of fluid
 Distribution of water and sodium in the body 9

intake and output; this is particularly pertinent for may be affected by pre-existing abnormalities of
unconscious patients. ‘Insensible loss’ is usually protein or red cell concentrations.
assumed to be about 1 L/day, but there is endogenous ● Haemoconcentration ECF is usually lost from
water production of about 500 mL/day as a result the vascular compartment first and, unless the
of metabolic processes. Therefore the net daily fluid is whole blood, depletion of water and small
‘insensible loss’ is about 500 mL. The required daily molecules results in a rise in the concentration of
intake may be calculated from the output during the large molecules, such as proteins and blood cells,
previous day plus 500 mL to allow for ‘insensible with a rise in blood haemoglobin concentration and
loss’; this method is satisfactory if the patient is haematocrit, raised plasma urea concentration and
normally hydrated before day-to-day monitoring reduced urine sodium concentration.
is started. Serial patient body weight determination
Table 2.4 shows various intravenous fluid regimens
can also be useful in the assessment of changes in
that can be used clinically. A summary of the British
fluid balance.
Consensus Guidelines on Intravenous Fluid Therapy
Pyrexial patients may lose 1 L or more of fluid in sweat
for Adult Surgical Patients (GIFTASUP) can be found
and, if they are also hyperventilating, respiratory water
at www.bapen.org.uk/pdfs/bapen_pubs/giftasup.pdf.
loss may be considerable. In such cases an allowance
of about 500 mL for ‘insensible loss’ may be totally DISTRIBUTION OF WATER AND SODIUM
inadequate. In addition, patients may be incontinent IN THE BODY
of urine, and having abnormal gastrointestinal losses In mild disturbances of the balance of water and
makes the accurate assessment of fluid losses very electrolytes, their total amounts in the body may be of
difficult. less importance than their distribution between body
Inaccurate measurement and charting are useless and compartments (see Table 2.2).
may be dangerous. Water is distributed between the main body
Keeping a cumulative fluid balance record is a useful fluid compartments, in which different electrolytes
way of detecting a trend, which may then be corrected contribute to the osmolality. These compartments are:
before serious abnormalities develop.
In the example shown in Table 2.3, 500 mL has been ● intracellular, in which potassium is the predominant
allowed for as net ‘insensible daily loss’; calculated losses cation,
are therefore more likely to be underestimated than ● extracellular, in which sodium is the predominant
overestimated. This shows how insidiously a serious cation, and which can be subdivided into:
deficit can develop over a few days. – interstitial space, with very low protein
The volume of fluid infused should be based on the concentration, and
calculated cumulative balance and on clinical evidence – intravascular (plasma) space, with a relatively
of the state of hydration, and its composition adjusted high protein concentration.
to maintain normal plasma electrolyte concentrations. Electrolyte distribution between cells and
Assessment of the state of hydration of a patient relies interstitial fluid
on clinical examination and on laboratory evidence of Sodium is the predominant extracellular cation, its
haemodilution or haemoconcentration. intracellular concentration being less than one-tenth
● Haemodilution Increasing plasma volume with of that within the ECF. The intracellular potassium
protein-free fluid leads to a fall in the concentrations concentration is about 30 times that of the ECF. About
of proteins and haemoglobin. However, these findings 95 per cent of the osmotically active sodium is outside

Table 2.3 Hypothetical cumulative fluid balance chart assuming an insensible daily loss of 500 mL

Measured intake (mL) Measured output (mL) Total output (minimum mL) Daily balance (mL) Cumulative balance (mL)
Day 1 2000 1900 2400 –400 –400
Day 2 2000 2000 2500 –500 –900
Day 3 2100 1900 2400 –300 –1200
Day 4 2200 2000 2500 –300 –1500
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