ELECTROLYTES, TRACE

ELEMENTS and VITAMINS

Introduction
 Introduction to Electrolytes, Trace Elements and
ELECTROLYTES Vitamins
Ø Dissociated ions carrying an electrical charge
Ø Cations: positively charged ions; migrates toward the cathode
Ø Anions: negatively charged; migrates toward the anode
Ø Generally, do not need a transport protein
MINERALS
Ø Inorganic homogenous solid substances essential for adequate bodily functions
Ø Classifications:
Ø Macrominerals (major elements): present in the body in quantities greater than 5 grams,
with a daily dietary requirement of 100 mg or more
Ø Microminerals (trace elements): <0.01% of dry body weight; metals except selenium &
halogens
Ø Trace elements: concentrations in mg/L (Iron, Copper, Zinc)
Ø Ultra-trace elements: concentrations in ug/L
 Introduction to Electrolytes, Trace Elements and
VITAMINS Vitamins
Ø Organic substances essential in minute quantities to the nutrition, acting as
coenzymes (or their precursors) in the regulation of metabolic process
Ø Do not provide energy and or serve as building units
Ø Some are produced by the body; others are present in food
ELECTROLYTES
 Liver Function
SYNTHESIS/METABOLISM AND STORAGE
1. Carbohydrates: glycogenesis, glycogenolysis, gluconeogenesis
*Galactose and fructose-->glucose
Upon reaching the liver carbohydrates (specifically glucose) are:
a. Used for its own energy requirements
b. Circulated for use at peripheral tissues
c. Stored as glycogen
2. Lipids: Free fatty acids→acetylCoA→TAG, Phospholipids, cholesterol
*Removal of lipids: lipoproteins and apoproteins
3. Plasma proteins (albumin, a- and b-globulins, enzymes, coagulation proteins,
etc.)
*Metabolism and storage of amino acids
4. Hormones (thyroid and steroid), Fat-soluble vitamins, Minerals/Metals
TRACE ELEMENTS
 Trace Elements
SPECIMEN CONSIDERATIONS
1. Whole blood, plasma (Heparinized) and serum
2. 24-hour urine: Polyethylene bottles with glacial acetic acid as preservative
3. Pre-analytical factors: age, sex, ethnic origin, time of day, food intake, medication,
tobacco usage

METHODOLOGY
1. Spectrophotometry
2. Atomic Absorption Spectrophotometry
3. Inductive Coupled Plasma-Optical Emission Spectrometry
4. Inductive Couple Plasma-Mass Spectrometry
 Iron
Ø Dietary Requirements: 8mg/L; Higher in menstruating women, children (~18 mg/L)
Ø Distribution: majority in hemoglobin; myoglobin; storage form-ferritin and
hemosiderin (BM, liver and spleen); transport: transferrin
Ø Absorption, Transport and Excretion:
Ø Only 10% of dietary iron is absorbed by the intestines
Ø Intestinal mucosal cells: Ferrous --> bound to apoferritin --> oxidized by ceruloplasmin -->
Ferric bound to ferritin --> Absorbed in the blood by apotransferrin --> Apotransferrin
becomes transferrin after binding two ferric ions
Ø Decrease in iron levels = inhibition of apoferritin formation = formation of transferrin
receptor
Ø Small amount excreted daily (urine/feces); 20-40 mg iron lost ever menstrual cycle
Ø Functions:
Ø Oxygen binding/delivery (ferrous form in hemoglobin)
Ø Myoglobin facilitate oxygen diffusion in tissues
Ø Enzyme constituent/cofactor (peroxidase, catalase, thyroperoxidase)
 Iron
Ø Iron deficiency anemia (15% of population)
Ø High Risk: Women (Pregnant, Reproductive age), children and adolescents
Ø Causes: Increased blood loss, decreased intake, decreased release from ferritin
Ø CBC results: Decreased RBC count, MCV and MCHC
Ø Hemochromatosis: collective term for iron overload disorders (excess absorption)
Ø Hemosiderosis: increased serum iron/TIBC/Transferrin; no tissue damage
Ø Hereditary hemochromatosis: Tissue accumulation; affects liver function; hyperpigmentation
of the skin
Ø Laboratory Methods for Iron Status
Ø CBC: Packed cell volume, Hemoglobin, RBC count and RBC Indexes
Ø Serum iron/Total iron content; Reference ranges (Serum iron): 3-5mg/L
Ø Total iron binding-capacity
Ø Percent Saturation = Total iron / TIBC x 100
Ø Transferrin (nephelometry) and Ferritin (Immunochemical: IRMA, ELISA)
 Zinc
Ø Second most abundant trace elment in the body (next to iron)
Ø Distribution: 60% in muscle, 30% in bones, the rest are in the liver, prostate, semen
Ø Absorption, Transport and Excretion:
Ø Increased absorption: Intake of calcium; presence of amino acids, animal proteins, and/or
unsaturated fatty acids in a meal
Ø Decreased absorption: intake of iron and high amounts of copper; Empty stomach; Age
Ø Absorbed in jejunum; ~65% transported by albumin, ~35% by A2-macroglobulin
Ø Functions:
Ø a.Most common metal cofactor for enzyme activity (>300 enzymes) *DNA/RNA polymerase
Ø b.Protein, glucose (affects insulin functions) and cholesterol metabolism
Ø c.Growth and wound healing (affects GH)
Ø d.Others: connective tissue integrity; reproductive functions; immune system
 Zinc
Ø Zinc deficiency: (has many various symptoms)
Ø Common in patients who have: DM, alcoholism, liver and kidney disease
Ø May cause teratogenic effects, fetal dysmaturity, neural tube defects and spina bifida if
deficiency occurs during pregnancy
Ø Acrodermatitis enteropathica = rare autosomal recessive disease
Ø impaired intestinal absorption and trans port of Zn
Ø Zinc excess: rarely occur as zinc is relatively non-toxic
Ø Inhalation of zinc oxide fumes = metal fume fever
Ø Excess in diet = copper depletion
Ø Respiratory manifestations, fever, leg and chest pain, vomiting
 Zinc
Ø Specimen Requirements
Ø Serum value is 10% higher than plasma (preferred)
Ø Diurnal variation: highest in the morning; decreased after meals, in the presence of
infections/inflammation, steroid administration, pregnancy, and hypoalbuminemia
Ø Laboratory Methods
Ø a.Atomic absorption spectroscopy = most reliable
Ø b.Spectrophotometry
Ø c.Emission spectroscopy
Ø d.Evaluation of zinc-containing enzymes may also be useful (ALP, carbonic anhydrase)
Ø Reference Ranges: 70-120 um/dL or 11-18 umol/L
 Copper
Ø Third most abundant trace elment in the body
Ø Distribution: Present in all living cells
Ø Absorption, Transport and Excretion:
Ø Decreased absorption: intake high amounts of iron and zinc
Ø Increased intake = decreased iron (IDA) and zinc absorption
Ø Copper-containing proteins: Transport proteins (Ceruloplasmin [60-95% ], albumin,
trancuprein), Metallothionein, Clotting Factor V
Ø *Henry's: Copper in ceruloplasmin is not exchangeable; thus, it is not its transport protein

Ø Functions:
Ø Component of enzymes involved in oxidation-reduction reactions (Ceruloplasmin,
Cytochrome C oxidase, Superoxide dismutases *w/ Zn, dopamine-B-hydroxylase,
tyrosinase)
 Copper
 Disorders
Ø Copper deficiency = uncommon
Ø Occur more in pindividuals with malnutrition and malababsorption
Ø May also be caused by increased zinc intake
Ø Neutropenia (early manifestation); IDA may be present when ceruloplasmin is low
Ø Severe deficiency = neurologic symptoms, decreased pigment
Ø Arrhytmia, hyperlipidemia and aneurisms leads to coronary heart disease
Ø Menke’s syndrome = X-linked recessive defect in copper transport leading to deficiency
Ø normal RBC copper, low serum/liver copper
Ø Manifestations: Metal retardation, failure to thrive, low enzyme activities, kinky/twisted/sheep wool
hair, connective tissue abnormalities
Ø Copper toxicity
Ø not reported from food intake
Ø Occurs mostly due to accidental ingestion of copper solutionn, IUD use, exposure to fungicides,
industrial exposure, excess supplements/contaminated water
Ø Causes nausea, vomiting, diarrhea, abdominal cramps, liver injury (more common in infants)
 Copper
Ø Disorders:
Ø Wilson’s disease (hepatolenticular degeneration)
Ø Copper transport from intestine to liver is normal but cannot be transported out of the liver, causing
copper accumulation in liver, brain, kidneys, cornea
Ø Manifestations: Low serum copper, high urine copper, Kayser-Fleischer rings (copper in cornea)
Ø Treatment: Zinc (*molybdenum) administration; Chelation therapy: Dimer-caprol, Penicillamine,
Ø Specimen Considerations
Ø Serum/plasma
Ø Diurnal variation: highest in the morning; increased in inflammation and pregnancy; steroid
hormones causes levels to decrease
Ø Reference Ranges (Serum): 750-1500ug/L
Ø Laboratory Methods
Ø a.Atomic Absorption Spectroscopy – widely used for direct copper measurement
Ø b.Ceruloplasmin – index of good copper status (indirect assessment)
Ø c. RBC superoxide dismutases (indirect assessment)
 Cobalt
Ø Distribution: Muscle, liver, fat
Ø Functions: Constituent of Vitamin B12, which is involved in folate metabolism and
erythropoiesis (DNA metabolism)
Ø Disorders:
Ø Cobalt deficiency = megaloblastic anemia, anorexia, stunted growth
Ø Cobalt toxicity = GI dysfunction, cardiomyopathy, hypothyroidism
Ø Specimen Requirements: serum, plasma, urine
Ø Laboratory Methods: Atomic Absorption Spectroscopy
Ø Reference ranges (Serum): 0.11-0.45 ug/L
 Chromium
Ø Glucose Tolerance Factor: biologically active form of chromium in brewer’s yeast
Ø Functions: Activator of insulin (glucose metabolism)
Ø Chromodulin = bind to chromium to enhance insulin receptor response
Ø Disorders:
Ø Deficiency (Prone to individuals with IV fluids, diabetes or malnutrition): Glucose intolerance,
Weight loss, Glycosuria, Hypercholesterolemia, Neurological symptoms, cardiovascular
problems, Impaired fertility (decreased sperm count in males)
Ø Toxicity: Transient renal defects (Low dose exposure); Skin disorders (e.g. dermatitis
[allergic and others], ulcers); Respiratory tract irritation; Liver, and immune system problems
Ø Specimen Requirements: Serum, plasma, whole blood, urine
Ø Laboratory Methods: Flameless atomic absorption
 Fluoride
Ø Most widely used of the pharmacologically beneficial trace element
Ø Functions: Integrity of the bones and the teeth *Closely associated to Vit D3
Ø Disorders:
Ø Toxicity: Mottled enamel, calcifications in the soft tissues, severe bone abnormalities
Ø Specimen Requirements: Serum, plasma, urine
Ø Laboratory Methods: Ion-selective electrodes
 Manganese
Ø 80% constituting ferromanganese
Ø Non-essential/non-specific: can be replaced by magnesium, iron, copper
Ø Transported in plasma by albumin, A2-macroglobulin and transferrin
Ø Functions: Activator of several enzymes like SODs (prevents oxygen toxicity),
pyruvate carboxylase (hepatic synthesis of glucose) and glycosyltransferase (bone
and skin integrity, wound healing)
Ø Disorders:
Ø Deficiency: Manganese is non-specific and can be substituted by Mg/Fe/Cu; thus,
minimizing effects of its deficiency
Ø Toxicity: High oral doses are not toxic; inhalation causes toxicity which may cause multiple
signs and symptoms
Ø Most involves hepatic and neurologic symptoms
Ø In chronic forms, may resemble Parkinson’s disease
Ø Locura manganica (manganese madness) = described in Chilean miners after aerosol intoxication
Ø A
 Manganese
Ø Specimen Requirements
Ø WB, RBC or lymphocyte concentration may be more reliable than serum/plasma in
assessing the tissue stores of manganese
Ø Urine manganese may be used in conjunction with serum manganese to evaluate the
possibility of toxicity or deficiency
Ø Laboratory Methods: Most practical is flameless atomic absorption with selective
chelation and extraction
 Molybdenum
Ø Absorbed at a high rate and may inhibit copper and iron absorption
Ø Functions
Ø Nucleic Acid catabolism/uric acid production
Ø hpoxanthine--xanthine oxidase--> uric acid
Ø molydopterin = cofactor of xanthine oxidase
Ø Treatment for Wilson’s diseases
Ø Disorders:
Ø Deficiency = Mental disturbances, Keratin formation defect, thyroid problems, hypouricemia
Ø Toxicity = Anemia, thyroid problems, hyperuricemia
Ø Specimen Requirements
Ø Serum/plasma/whole blood too low to detect deficiency; urine is more responsive to
increases or decreases of intake, especially urate or sulfite measurement in urine
 Selenium
Ø Functions:
Ø Enzyme constituent (glutathione peroxidase, iodothyronine deiodinase)
Ø Considered to have close association with Vitamin E and its functions (anti-oxidant;
protection from free radicals)
Ø Thyroid hormone metabolism
Ø Specimen Requirements: serum, plasma, whole blood, RBC
Ø Laboratory Methods: Atomic absorption spectroscopy
VITAMINS
 Introduction
SOLUBILITY
Ø 1.Fat-soluble vitamins include A, D, E, and K.
Ø 2.Water-soluble vitamins include C, ascorbic acid; B1, thiamin; B2, riboflavin; B6,
pyridoxine; B12, cobalamin; niacin, nicotinic acid; pantothenic acid; biotin; folate,
folic acid
METABOLISM
Ø 1.Fat-soluble vitamins stored in liver or adipose tissue; may accumulate to toxic
levels
Ø 2.Water-soluble vitamins easily excreted in urine; generally do not accumulate to
toxic levels
 Functions
Ø 1.Vitamin A: Vision in dim light (most clearly defined), cellular differentiation, growth,
reproduction, immunity
Ø 2.Vitamin D: Proper skeleton formation and mineral homeostasis (Promotes
absorption of calcium and phosphorus); Pro-apoptopic effect
Ø 3.Vitamin E: Antioxidant, scavenge free radicals; RBC integrity; Cellular respiration
(esp. In muscles) strengthen cell membranes; augment drug metabolism, heme
biosynthesis, and neuromuscular function
Ø 4.Vitamin K: Formation of coagulation proteins (serves as cofactor)
Ø 5.Vitamin C: Coenzyme in oxidation-reduction reactions; hydroxylation of collagen
Ø 6.Vitamin B1: Coenzyme in decarboxylation reactions in carbohydrate pathways
and branched-chain amino acid metabolism
Ø 7.Vitamin B2: Component of coenzymes (flavin mononucleotide and flavin adenine
dinucleotide) which catalyzes various oxidation-reduction reactions
 Functions
Ø 8.Vitamin B6: Coenzymes in intermediary reactions; amino acid, phospholipid and
glycogen metabolism
Ø 9.Vitamin B12: Hematopoiesis-DNA synthesis; fatty acid metabolism
Ø 10.Vitamin B3: component of coenzymes (NAD and NADP)associated for oxidation-
reduction reactions necessary for various metabolic processes including tissue
respiration, and lipid, fatty acid and glucose metabolism
Ø 11.Vitamin B5: Incorporated in coenzyme A
Ø 12.Vitamin B7: Cofactor in carboxylation reactions in glucose; lipid and fatty acid
synthesis
Ø 13.Vitamin B9: Hematopoiesis-DNA synthesis; Amino acid synthesis
 Clinical Significance - Deficiency
Ø 1.Vitamin A (Retinal, Retinol, Retinoic acid) deficiency: Drying, degeneration, and
increased risk of infection in conjunctiva, cornea, skin, and mucous membranes;
night blindness (Nyctalopia), xeropthalmia; Growth retardation; Abnormal taste
response; Reproductive disorders, vulnerability to infection
Ø 2.Vitamin D (Cholecalciferol) deficiency: Rickets, osteomalacia, osteoporosis,
hypocalcemia, tetany
Ø 3.Vitamin E (A-Tocopherol) deficiency: Hemolytic disease of premature neonates;
RBC fragility; Ataxia; Spinocerebellar degeneration
Ø 4.Vitamin K deficiency: Easy bruising to massive bruising; Hemorrhage, Post-
traumatic bleeding
Ø 5.Vitamin C (Ascorbic acid) deficiency: Acute: Vague aches and pains; Chronic:
Scurvy, necrosis of gums, emotional disturbances
 Clinical Significance - Deficiency
Ø 6.Vitamin B1 (Thiamine) deficiency: Infants: Dyspnea, Cyanosis, Diarrhea and
Vomiting Adults: Beriberi, Wernicke-Korsakoff syndrome
Ø 7.Vitamin B2 (Riboflavin) deficiency: Cheilosis, angular stomatitis, glossitis,
seborrheic dermatitis, ocular disturbances/photophobia, neurologic changes
Ø 8.Vitamin B6 (Pyridoxine,Pyridoxal, Pyridoxamine) deficiency: Infants: Irritability,
seizures, anemia, vomiting, weakness Adults: Eczema, seborrheic dermatitis,
cheilosis, glossitis, angular stomatitis, mental depression, anemia
Ø 9.Vitamin B12 (Cobalamin) deficiency: Hematologic effects, including macrocytic
anemia, and neurologic effects, including peripheral nerve degeneration
Ø 10.Vitamin B3 (Niacin-nicotinic acid, nicotinamide) deficiency: Pellagra: dementia,
dermatitis, diarrhea
Ø 11.Vitamin B5 (Pantothenic acid) deficiency: Metabolism affected; causes nausea,
vomiting, muscular weakness, malaise; (Henry’s: no syndrome recognized)
 Clinical Significance - Deficiency
Ø 12.Vitamin B7 (Biotin) deficiency: Cutaneous, ophthalmic, and neurologic symptoms
*Rare: commonly due to to lack of biotin in total parenteral nutrition
Ø 13.Vitamin B9 (Folate,Folic acid) deficiency: Megaloblastic anemia, anorexia,
glossitis, nausea hepatosplenomegaly, hyperpigmentation of skin, neural tube
defects
 Clinical Significance - Toxicity
Ø 1.Vitamin A: Acute: Can cause drowsiness, headache, vomiting, stupor, skin peeling,
and papilledema Chronic: Teratogenic, osteoporosis, hepatotoxicity. Carotenoids in
excess, distinct orange-yellow skin color
Ø 2.Vitamin D: Hypercalcemia and hypercalciuria; Bone demineralization, constipation,
muscle weakness, renal calculi
Ø 3.Vitamin E: Mild GI distress, nausea, coagulopathies in patients receiving
anticonvulsants (Bishop: do not produce toxic effects)
Ø 4.Vitamin K: Excess amounts of vitamin K may decrease clotting time (Bishop: not
commonly seen in adults; hyperbilirubinemia in infants)
Ø 5.Vitamin C: Chronic megadoses of 10–150 times the RDA (1–15 g), cramps,
diarrhea, nausea, kidney stones. With megadoses, body accelerates drug
metabolism (interfering with its action); May interfere with Vitamin B12 metabolism;
Can produce scurvy if megadoses abruptly stop
 Clinical Significance - Toxicity
Ø 1.Vitamin A: Acute: Can cause drowsiness, headache, vomiting, stupor, skin peeling, and papilledema Chronic: Teratogenic, osteoporosis,
hepatotoxicity. Carotenoids in excess, distinct orange-yellow skin color
Ø 2.Vitamin D: Hypercalcemia and hypercalciuria; Bone demineralization, constipation, muscle weakness, renal calculi
Ø 3.Vitamin E: Mild GI distress, nausea, coagulopathies in patients receiving anticonvulsants (Bishop: do not produce toxic effects)
Ø 4.Vitamin K: Excess amounts of vitamin K may decrease clotting time (Bishop: not commonly seen in adults; hyperbilirubinemia in infants)
Ø 5.Vitamin C: Chronic megadoses of 10–150 times the RDA (1–15 g), cramps, diarrhea, nausea, kidney stones. With megadoses, body
accelerates drug metabolism (interfering with its action); May interfere with Vitamin B12 metabolism; Can produce scurvy if megadoses
abruptly stop
Ø 6.Vitamin B1: Only when given parenterally. Headache, muscle weakness, cardiac arrhythmia, convulsions
Ø 7.Vitamin B2: Toxicity to riboflavin has not been reported. Absorption limited normally
Ø 8.Vitamin B6: Long-term megadose supplementation causes ataxia and sensory neuropathy.
Ø 9.Vitamin B12: No appreciable toxicity
Ø 10.Vitamin B3: Excess pre-formed niacin and nicotinic acid cause vascular dilation, “flushing”; hepatotoxic (Lipid-lowering therapies)
Ø 11.Vitamin B5: Very high doses: Diarrhea
Ø 12.Vitamin B7: No known toxicity
Ø 13.Vitamin B9: No adverse effects at high oral doses
 Clinical Significance - Toxicity
Ø 6.Vitamin B1: Only when given parenterally. Headache, muscle weakness, cardiac
arrhythmia, convulsions
Ø 7.Vitamin B2: Toxicity to riboflavin has not been reported. Absorption limited
normally
Ø 8.Vitamin B6: Long-term megadose supplementation causes ataxia and sensory
neuropathy.
Ø 9.Vitamin B12: No appreciable toxicity
Ø 10.Vitamin B3: Excess pre-formed niacin and nicotinic acid cause vascular dilation,
“flushing”; hepatotoxic (Lipid-lowering therapies)
Ø 11.Vitamin B5: Very high doses: Diarrhea
Ø 12.Vitamin B7: No known toxicity
Ø 13.Vitamin B9: No adverse effects at high oral doses
 Laboratory MEthods
Ø HPLC, Fluorometric assays, liquid chromatography-tandem mass spectrometry,
spectrophotometry, electrochemical assays
Ø Competitive protein-binding assays, immunoassays, enzyme activation tests, RIA
Ø Microbiological assays, bioassays