Medical Laboratory Science Review Harr 5.2 Chemistry - Blood Gases, pH, and Electrolytes (36-70)
Which of the following values is the threshold critical value (alert or action level) for high plasma sodium? A. 150 mmol/L B. 160 mmol/L C. 170 mmol/L D. 180 mmol/L
B. 160 mmol/L B The adult reference range for plasma sodium is approximately 135-145 mmol/L. Levels in excess of 160 mmol/L are associated with severe dehydration, hypovolemia, and circulatory and heart failure. The threshold for the low critical value for sodium is 120 mmol/L. This is associated with edema, hypervolemia, and circulatory overload. Alert levels must also be established for potassium, bicarbonate, calcium, pH, PO2, glucose, bilirubin, hemoglobin, platelet count, and prothrombin time. When a sample result is below or above the low or high alert level, respectively, the physician must be notified immediately.
Given the following serum electrolyte data, determine the anion gap. Na = 132 mmol/L Cl = 90 mmol/L HCO3- = 22 mmol/L A. 12 mmol/L B. 20 mmol/L C. 64 mmol/L D. Cannot be determined from the information provided
B. 20 mmol/L B The anion gap is defined as unmeasured anions minus unmeasured cations. It is calculated by subtracting the measured anions (bicarbonate and chloride) from the serum sodium (or sodium plus potassium). A normal anion gap is approximately 8-16 mmol/L (12-20 mmol/L when potassium is used). Anion gap = Na - (HCO3 + Cl) Anion gap = 132 - (90 + 22) = 20 mmol/L
What is the percentage of serum calcium that is ionized (Cai)? A. 30% B. 45% C. 60% D. 80%
B. 45% B Calcium exists in serum in three forms: protein bound, ionized, and complexed (as undissociated salts). Only Cai is physiologically active. Protein bound and Cai each account for approximately 45% of total calcium, and the remaining 10% is complexed.
When measuring calcium with the complexometric dye o-cresolphthalein complexone, magnesium is kept from interfering by: A. Using an alkaline pH B. Adding 8-hydroxyquinoline C. Measuring at 450 nm D. Complexing to EDTA
B. Adding 8-hydroxyquinoline B o-Cresolphthalein complexone can be used to measure either magnesium or calcium. Interference in calcium assays is prevented by addition of 8-hydroxyquinoline, which chelates magnesium. When magnesium is measured, ethyleneglycol bistetraacetic acid (EGTA) or EDTA is used to chelate calcium. Two other dyes that can be used for both magnesium and calcium assays are calmagite and methylthymol blue. Arsenazo III dye is commonly used to measure calcium. It is more specific for Ca+2 than the others, and does not require addition of a Mg+2 chelator.
Which of the following conditions will cause erroneous Cai results? Assume that the samples are collected and stored anaerobically, kept at 4°C until measurement, and stored for no longer than 1 hour. A. Slight hemolysis during venipuncture B. Assay of whole blood collected in sodium oxalate C. Analysis of serum in a barrier gel tube stored at 4°C until the clot has formed D. Analysis of whole blood collected in sodium heparin, 20 U/mL (low-heparin tube)
B. Assay of whole blood collected in sodium oxalate B Unlike Pi, the intracellular calcium level is not significantly different from plasma calcium, and calcium is not greatly affected by diet. Whole blood collected with 5-20 U/mL heparin and stored on ice no longer than 2 hours is the sample of choice for Cai. Blood gas syringes prefilled with 100 U/mL heparin should not be used because the high heparin concentration will cause low results. Citrate, oxalate, and ethylenediaminetetraacetic acid (EDTA) must not be used because they chelate calcium. Serum may be used provided that the sample is iced, kept capped while clotting, and assayed within 2 hours (barrier gel tubes may be stored longer).
Which electrolyte measurement is least affected by hemolysis? A. Potassium B. Calcium C. Pi D. Magnesium
B. Calcium B Potassium, phosphorus, and magnesium are the major intracellular ions, and even slight hemolysis will cause falsely elevated results. Serum samples with visible hemolysis (20 mg/dL free Hgb) should be redrawn.
Which of the following is the primary mechanism for vasopressin (ADH) release? A. Hypovolemia B. Hyperosmolar plasma C. Renin release D. Reduced renal blood flow
B. Hyperosmolar plasma B ADH is released by the posterior pituitary in response to increased plasma osmolality. Normally, this is triggered by release of aldosterone caused by ineffective arterial pressure in the kidney. Aldosterone causes sodium reabsorption, which raises plasma osmolality; release of ADH causes reabsorption of water, which increases blood volume and restores normal osmolality. A deficiency of ADH (diabetes insipidus) results in dehydration and hypernatremia. An excess of ADH (syndrome of inappropriate ADH release [SIADH]) results in dilutional hyponatremia. This may be caused by regional hypovolemia, hypothyroidism, central nervous system injury, drugs, and malignancy.
Which formula is most accurate in predicting plasma osmolality? A. Na + 2(Cl) + BUN + glucose B. 2(Na) + 2(Cl) + glucose + urea C. 2(Na) + (glucose ÷ 18) + (BUN ÷ 2.8) D. Na + Cl + K + HCO3
C. 2(Na) + (glucose ÷ 18) + (BUN ÷ 2.8) C Calculated plasma osmolality is based upon measurement of sodium, glucose, and urea. Because sodium associates with a counter ion, two times the sodium estimates the millimoles per liter of electrolytes. Some laboratories multiply by 1.86 instead of 2 to correct for undissociated salts. Dividing glucose by 18 converts from milligrams per deciliter to millimoles per liter. Dividing blood urea nitrogen (BUN) by 2.8 converts from milligrams per deciliter BUN to millimoles per liter urea.
Which of the following values is the threshold critical value (alert or action level) for low plasma potassium? A. 1.5 mmol/L B. 2.0 mmol/L C. 2.5 mmol/L D. 3.5 mmol/L
C. 2.5 mmol/L C The reference range for potassium is 3.6-5.4 mmol/L. However, values below 2.5 mmol/L require immediate intervention because below that level there is a grave risk of cardiac arrhythmia, which can lead to cardiac arrest. The upper alert level for potassium is usually 6.5 mmol/L, except for neonatal and hemolyzed samples. Above this level, there is danger of cardiac failure
What role do CTx and NTx play in the management of osteoporosis? A. Increased urinary excretion is diagnostic of early stage disease B. Increased levels indicate a low risk of developing osteoporosis C. Decreased urinary excretion indicates a positive response to treatment D. The rate of urinary excretion correlates with the stage of the disease
C. Decreased urinary excretion indicates a positive response to treatment C Markers for both bone formation and resorption are used to monitor treatment for osteoporosis. Serum and urinary measurements of CTx and NTx and urinary deoxypyridinoline are used to monitor medications such as biphosphonates that inhibit bone resorption. Levels fall with successful treatment. DEXA scan, an x-ray procedure based on subtraction of surrounding tissue, is the most sensitive diagnostic test for osteoporosis and can show bone loss as small as 1%. However, it takes months before a DEXA scan shows increased bone remodeling following treatment.
Which of the following is the most accurate measurement of Pi in serum? A. Rate of unreduced phosphomolybdate formation at 340 nm B. Measurement of phosphomolybdenum blue at 680 nm C. Use of aminonaptholsulfonic acid to reduce phosphomolybdate D. Formation of a complex with malachite green dye
A. Rate of unreduced phosphomolybdate formation at 340 nm A The colorimetric method (Fiske and SubbaRow) used previously for Pi reacted ammonium molybdate with Pi, forming ammonium phosphomolybdate (NH4)3[PO4(MoO3)12]. A reducing agent, aminonaptholsulfonic acid (ANS), was added, forming phosphomolybdenum blue. The product was unstable and required sulfuric acid, making precipitation of protein a potential source of error. These problems are avoided by measuring the rate of formation of unreduced phosphomolybdate at 340 nm
Which of the following conditions is associated with total body sodium excess? A. Renal failure B. Hyperthyroidism C. Hypoparathyroidism D. Diabetic ketoacidosis
A. Renal failure A Total body sodium excess often occurs in persons with renal failure, congestive heart failure, and cirrhosis of the liver. When water is retained along with sodium, total body sodium excess results rather than hypernatremia. Heart failure causes sodium and water retention by reducing blood flow to the kidneys. Cirrhosis causes obstruction of hepatic lymphatics and portal veins, leading to local hypertension and accumulation of ascites fluid. Renal failure results in poor glomerular filtration and isosmotic equilibration of salt and water.
Which of the following conditions is associated with hypophosphatemia? A. Rickets B. Multiple myeloma C. Renal failure D. Hypervitaminosis D
A. Rickets A Rickets can result from dietary phosphate deficiency, vitamin D deficiency, or an inherited disorder of either vitamin D or phosphorus metabolism. Vitamin D-dependent rickets (VDDR) can be reversed by megadoses of vitamin D. Type 1 is caused by a deficiency in renal cells of 1-α-hydroxylase, an enzyme that converts 25 hydroxyvitamin D to the active form, 1,25 hydroxyvitamin D. Type 2 is caused by a deficiency in the vitamin D receptor of bone tissue. Vitamin D-resistant rickets (VDRR) is caused by a deficiency in the renal reabsorption of phosphate. Consequently, affected persons (usually men because it is most commonly X-linked) have a normal serum calcium and a low Pi.
Which electrolyte level best correlates with plasma osmolality? A. Sodium B. Chloride C. Bicarbonate D. Calcium
A. Sodium A Sodium and chloride are the major extracellular ions. Chloride passively follows sodium, making sodium the principal determinant of plasma osmolality
Which of the following laboratory results is usually associated with cystic fibrosis? A. Sweat chloride greater than 60 mmol/L B. Elevated serum sodium and chloride C. Elevated fecal trypsin activity D. Low glucose
A. Sweat chloride greater than 60 mmol/L A Cystic fibrosis causes obstruction of the exocrine glands including the sweat glands, mucus glands, and pancreas. Newborns with pancreatic involvement demonstrate fecal trypsin deficiency, which may be detected by a low fecal chymotrypsin or immunoreactive trypsin result. However, these tests require confirmation. Serum sodium and chloride levels are low. More than 98% of affected infants have elevated sweat sodium and chloride and low serum levels. Sweat chloride in excess of 60 mmol/L confirms the clinical diagnosis. Some persons with the disease have insulin deficiency and elevated blood glucose. Genetic tests are available to detect several mutations that occur at the cystic fibrosis transmembrane conductance regulator (CFTR) locus on chromosome 7
Which of the following conditions involving electrolytes is described correctly? A. Pseudohyponatremia occurs only when undiluted samples are measured B. Potassium levels are slightly higher in heparinized plasma than in serum C. Hypoalbuminemia causes low total calcium but does not affect Cai D. Hypercalcemia may be induced by low serum magnesium
C. Hypoalbuminemia causes low total calcium but does not affect Cai C When serum albumin is low, the equilibrium between bound and Cai is shifted, producing increased Cai . This inhibits release of PTH by negative feedback until the Cai level returns to normal. Potassium is released from platelets and leukocytes during coagulation, causing serum levels to be higher than plasma. Pseudohyponatremia is a measurement error caused by diluting samples containing excessive fat or protein. The colloids displace plasma water, resulting in less electrolytes being delivered into the diluent. Only ion-selective electrodes that measure whole blood or undiluted serum are unaffected. Magnesium is needed for release of PTH, and PTH causes release of calcium and magnesium from bone. Therefore, hypocalcemia can be associated with either magnesium deficiency or magnesium excess.
Which of the following conditions is associated with hypokalemia? A. Addison's disease B. Hemolytic anemia C. Digoxin intoxication D. Alkalosis
D. Alkalosis D Addison's disease (adrenocortical insufficiency) results in low levels of adrenal corticosteroid hormones, including aldosterone and cortisol. Because these hormones promote reabsorption of sodium and secretion of potassium by the collecting tubules, patients with Addison's disease display hyperkalemia and hyponatremia. Hemolytic anemia and digoxin intoxication cause release of intracellular potassium. Alkalosis causes potassium to move from the extracellular fluid into the cells as hydrogen ions move from the cells into the extracellular fluid to compensate for alkalosis.
Which of the following conditions is most likely to produce an elevated plasma potassium? A. Hypoparathyroidism B. Cushing's syndrome C. Diarrhea D. Digitalis overdose
D. Digitalis overdose D Digitalis toxicity causes potassium to leave the cells and enter the extracellular fluid, resulting in hyperkalemia. Renal failure, hemolytic anemia and Addison's disease are other frequent causes of hyperkalemia. Hypoparathyroidism indirectly causes hypokalemia by inducing alkalosis via increased renal retention of phosphate and bicarbonate. Cushing's syndrome (adrenal cortical hyperfunction) results in low potassium and elevated sodium. Diarrhea causes loss of sodium and potassium.
Which condition can result in acidosis? A. Cystic fibrosis B. Vomiting C. Hyperaldosteronism D. Excessive O2 therapy
D. Excessive O2 therapy D When O2 saturation of venous blood is greatly elevated, Hgb cannot release O2. Oxyhemoglobin cannot bind CO2 or hydrogen ions and acidosis results. Pure O2 may cause neurological damage, leading to convulsion and blindness, especially in infants. It can induce respiratory failure by causing pulmonary hemorrhage, edema, and hyalinization. The other three conditions cause alkalosis. Vomiting and cystic fibrosis cause loss of chloride, resulting in hypovolemia and intestinal bicarbonate absorption. Hyperaldosteronism causes hypokalemia; this results in increased renal H+ excretion and a shift of H+ into cells in exchange for K+
Which of the following tests is consistently abnormal in osteoporosis? A. High urinary calcium B. High serum Pi C. Low serum calcium D. High urine or serum N-telopeptide of type 1 collagen
D. High urine or serum N-telopeptide of type 1 collagen D Commonly used markers for other bone diseases such as serum or urinary calcium, inorganic phosphorus, total alkaline phosphatase (ALP), and vitamin D are neither sensitive nor specific for osteoporosis. Calcium and phosphorus are usually within normal limits. Although estrogen deficiency reduces formation of 1,25 hydroxyvitamin D (1,25 hydroxycholecalciferol), promoting postmenopausal osteoporosis, the 1,25 hydroxyvitamin D is low in only 30%-35% of cases, and low levels may be caused by other bone disorders. Serum markers for osteoporosis include both N-telopeptide of type 1 collagen (NTx) and C-telopeptide of type 1 collagen (CTx). These can be used to follow treatment with resorption antagonists (bisphosphonates) because they decrease significantly when therapy is successful.
Which of the following conditions is associated with an increase in ionized calcium (Cai) in the blood? A. Alkalosis B. Hypoparathyroidism C. Hyperalbuminemia D. Malignancy
D. Malignancy D Increased Cai occurs in hyperparathyroidism, malignancy, and acidosis. Cai is elevated in primary hyperparathyroidism due to resorption of calcium from bone. Many nonparathyroid malignancies create products called parathyroid hormone-related proteins that stimulate the parathyroid receptors of cells. Acidosis alters the equilibrium between bound and free calcium, favoring ionization. Hyperalbuminemia increases the total calcium by increasing the proteinbound fraction, but does not affect the Ca
Which of the following conditions is associated with a low serum magnesium? A. Addison's disease B. Hemolytic anemia C. Hyperparathyroidism D. Pancreatitis
D. Pancreatitis D Low magnesium can be caused by gastrointestinal loss, as occurs in diarrhea and pancreatitis (loss of Mg and Ca as soaps). Hyperparathyroidism causes increased release of both calcium and magnesium from bone. Addison's disease (adrenocorticosteroid deficiency) may be associated with increased magnesium accompanying hyperkalemia. Hemolytic anemia causes increased release of magnesium as well as potassium from damaged red blood cells (RBCs).
Which of the following conditions will cause an increased anion gap? A. Diarrhea B. Hypoaldosteronism C. Hyperkalemia D. Renal failure
D. Renal failure D An increased anion gap occurs when there is production or retention of anions other than bicarbonate or chloride (measured anions). For example, in renal failure, retention of phosphates and sulfates (as sodium salts) increases the anion gap. Other common causes of metabolic acidosis with an increased anion gap are diabetic ketoacidosis and lactate acidosis. The anion gap may also be increased in the absence of an acid-base disorder. Common causes include hypocalcemia, drug overdose, and laboratory error when measuring electrolytes.
Which electrolyte is least likely to be elevated in renal failure? A. Potassium B. Magnesium C. Inorganic phosphorus D. Sodium
D. Sodium D Reduced glomerular filtration coupled with decreased tubular secretion causes accumulation of potassium, magnesium, and inorganic phosphorus. Poor tubular reabsorption of sodium offsets reduced glomerular filtration. Unfiltered sodium draws both chloride and water, causing osmotic equilibration between filtrate, serum, and the tissues. In renal disease, serum sodium is often normal, although total body sodium is increased owing to fluid and salt retention.
What role does vitamin D measurement play in the management of osteoporosis? A. Vitamin D deficiency must be demonstrated to establish the diagnosis B. Vitamin D is consistently elevated in osteoporosis C. A normal vitamin D level rules out osteoporosis D. Vitamin D deficiency is a risk factor for developing osteoporosis
D. Vitamin D deficiency is a risk factor for developing osteoporosis D Vitamin D assay is not used to diagnose osteoporosis. Vitamin D deficiency is a cause of secondary osteoporosis, and together with low PTH, calcium, and estrogen are important risk factors. If one or more of these is abnormal, then bone resorption or remodeling may be abnormal, predisposing one to osteoporosis. Deficiency of vitamin D also causes rickets (called osteomalacia in adults), a condition in which bones become soft owing to reduced deposition of hydroxyapatite.
Alcoholism, liver failure, and hypoxia induce acidosis by causing: A. Depletion of cellular NAD+ B. Increased excretion of bicarbonate C. Increased retention of PCO2 D. Loss of carbonic anhydrase
A. Depletion of cellular NAD+ A Oxygen debt and liver failure block oxidative phosphorylation, preventing NADH from being oxidized back to NAD+. Oxidation of ethanol to acetate results in accumulation of NADH. When NAD+ is depleted, glycolysis cannot proceed. It is regenerated by reduction of pyruvate to lactate, causing lactate acidosis.
Which of the following conditions is associated with hypernatremia? A. Diabetes insipidus B. Hypoaldosteronism C. Burns D. Diarrhea
A. Diabetes insipidus A Diabetes insipidus results from failure to produce ADH. Because the collecting tubules are impermeable to water in the absence of ADH, severe hypovolemia and dehydration result. Hypovolemia stimulates aldosterone release, causing sodium reabsorption, which worsens the hypernatremia. Burns, hypoaldosteronism, diarrhea, and diuretic therapy are common causes of hyponatremia.
Which of the following conditions is associated with hyponatremia? A. Diuretic therapy B. Cushing's syndrome C. Diabetes insipidus D. Nephrotic syndrome
A. Diuretic therapy A Diuretics lower blood pressure by promoting water loss. This is accomplished by causing sodium loss from the proximal tubule and/or loop. Addison's disease, syndrome of inappropriate ADH release, burns, diabetic ketoacidosis, hypopituitarism, vomiting, diarrhea, and cystic fibrosis also cause hyponatremia. Cushing's syndrome causes hypernatremia by promoting sodium reabsorption in the collecting tubule in exchange for potassium. Diabetes insipidus and nephrotic syndrome promote hypernatremia by causing water loss
Which of the following is the primary mechanism causing respiratory alkalosis? A. Hyperventilation B. Deficient alveolar diffusion C. Deficient pulmonary perfusion D. Parasympathetic inhibition
A. Hyperventilation A Hyperventilation via stimulation of the respiratory center (or induced by a respirator) is the mechanism of respiratory alkalosis. Causes include low PO2, anxiety, fever, and drugs that stimulate the respiratory center. Acute respiratory alkalosis is often uncompensated because renal compensation is not rapid. Uncompensated respiratory alkalosis is characterized by an elevated pH and a low PCO2 with normal bicarbonate.
Which of the following laboratory results is consistent with primary hypoparathyroidism? A. Low calcium; high inorganic phosphorus Pi B. Low calcium; low Pi C. High calcium; high Pi D. High calcium; low Pi
A. Low calcium; high inorganic phosphorus Pi A Parathyroid hormone deficiency causes reduced resorption of calcium from bone, increased renal excretion of calcium, and decreased renal excretion of phosphorus. It is distinguished from other causes of hypocalcemia by Cai , which is reduced only by primary hypoparathyroidism and alkalosis.
Which of the following is a marker for bone formation? A. Osteocalcin B. Tartrate resistant acid phosphatase (TRAP) C. Urinary pyridinoline and deoxypyridinoline D. Urinary C-telopeptide and N-telopeptide crosslinks (CTx and NTx
A. Osteocalcin A Biochemical markers for osteoporosis are classified as either markers for bone formation or resorption. Osteocalcin is a proteinhormone that stimulates osteoblasts and increases bone mineralization. Pyridinoline is formed when hydroxylysine groups on adjacent fibrils are joined together, and deoxypyridinoline when hydroxylysine and lysine groups are joined. These form crosslinks between the C and N terminal ends of one fibril (which are nonhelical) and the helical portion of an adjacent fibril. The resulting products are called C- and N-telopeptide crosslinks of type 1 collagen. Osteoclasts cause cleavage of these bonds, resulting in loss of both telopeptides—deoxypyridinoline and pyridinoline—in the urine. TRAP is an enzyme (produced by osteoclasts) that hydrolyzes phosphate in the hydroxyapatite matrix of the bone.
When performing a sweat chloride collection, which of the following steps will result in analytical error? A. Using unweighed gauze soaked in pilocarpine nitrate on the inner surface of the forearm to stimulate sweating B. Collecting more than 75 mg of sweat in 30 minutes C. Leaving the preweighed gauze on the inside of the arm exposed to air during collection D. Rinsing the collected sweat from the gauze pad using chloride titrating solution
C. Leaving the preweighed gauze on the inside of the arm exposed to air during collection C The sweat chloride procedure requires the application of pilocarpine to stimulate sweating, and the use of iontophoresis (application of 0.16-mA current for 5 minutes) to bring the sweat to the surface. After iontophoresis, the skin on the inner surface of the forearm is washed with deionized water and dried, and a preweighed pair of 2-in.2 pads is taped to the skin. During the 30-minute collection of sweat, the gauze must be completely covered to prevent contamination and loss of sweat by evaporation. The Gibson-Cooke reference method for sweat chloride uses the Schales and Schales method (titration by Hg[NO3]2 with diphenylcarbazone indicator) to assay 1.0 mL of sweat eluted from the gauze with 5 mL of water. A Cotlove chloridometer is often used to measure sweat chloride. The sweat is eluted from the gauze with the titrating solution to facilitate measurement. Alternatively, a macroduct collection system may be used that does not require weighing. A minimum mass of 75 mg sweat is required for collection in gauze and 15 μL sweat for collection in macroduct tubing
In which condition would hypochloremia be expected? A. Respiratory alkalosis B. Metabolic acidosis C. Metabolic alkalosis D. All of these options
C. Metabolic alkalosis C Chloride is the major extracellular anion and is retained or lost to preserve electroneutrality. Low chloride will occur in metabolic alkalosis because excess bicarbonate is present. Low chloride also will occur in partially compensated respiratory acidosis because the kidneys compensate by increased retention of bicarbonate.
The serum level of which of the following laboratory tests is decreased in both VDDR and VDRR? A. Vitamin D B. Calcium C. Pi D. Parathyroid hormone
C. Pi C Persons with VDDR and VDRR have a low Pi. However, persons with VDDR have decreased serum calcium, as well. Parathyroid hormone (PTH) is increased in persons with VDDR because calcium is the primary stimulus for PTH release, but not in persons with VDRR. Vitamin D levels vary depending upon the type of rickets and the vitamin D metabolite that is measured. 1,25(OH)D, the active form of vitamin D, is low in type 1 but high in type 2 VDDR. It may be either normal or low in VDRR.
Which statement best describes testing recommendations for vitamin D? A. Vitamin D testing should be reserved only for those persons who demonstrate hypercalcemia of an undetermined cause B. Vitamin D testing should be specific for the 1,25(OH)D3 form C. Testing should be for total vitamin D when screening for deficiency D. Vitamin D testing should not be performed if the patient is receiving a vitamin D supplement
C. Testing should be for total vitamin D when screening for deficiency C Vitamin D deficiency is far more common than vitamin D excess, and screening for vitamin D deficiency is advocated especially for dark-skinned persons and people who do not get adequate sunlight. Provitamin D is a steroid, and vitamin D is now considered a hormone rather than a vitamin. The hormone regulates transcription of over 200 genes and has pronounced effects on both dendritic cells and T lymphocytes. Deficiency is associated with many chronic diseases including autoimmune diseases, cancers, hypertension, and heart disease. There are two forms of the vitamin, ergocalciferol (D2) and cholecalciferol (D3). Active D2 and D3 are formed when two hydroxyl groups are added, the first being at the 25 position by the liver and the second at the α-1 position by the kidney. The majority of the circulating vitamin D is in the 25-hydroxylated form of D2 and D3, called 25(OH)D. The plasma 25(OH)D concentration is an expression of both dietary and endogenous vitamin D and is the most appropriate test for detecting nutritional vitamin D deficiency. Since the effect on calcium is derived from the active 1,25 form of the vitamin, plasma 1,25(OH)D concentration is a more specific test for hypervitaminosis D