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Transcript liver-function-tests
D- LIVER FUNCTION TESTS
Introduction
Liver has to perform different kinds of biochemical,
synthetic and excretory functions
no single biochemical test can detect the global functions
of liver.
All laboratories usually employ a battery of tests for
initial detection and management of liver diseases
These tests are frequently termed “Liver function tests”.
Normal liver function
The various functions of the liver are carried out by the
liver cells or hepatocytes
a) Metabolic function
carbohydrate metabolism
Gluconeogenesis
Glycogenolysis
Glycogenesis
protein metabolism, synthesis as well as degradation
lipid metabolism:
Cholesterol synthesis
Lipogenesis, the production of triglycerides (fats)
b) Storage functions
glucose (in the form of glycogen),
Vitamins A , D, E, B12
iron, and copper.
.
c) Synthetic function
coagulation factors I (fibrinogen) , II
(prothrombin), V, VII, IX, X and XI, as well as
protein C, protein S and antithrombin
produces and excretes bile (a yellowish liquid)
required for emulsifying fats.
Synthesizes albumin
d) Detoxification :
ammonia to urea
Drugs and drug metabolites
e)Immunological - the reticuloendothelial
system of the liver contains many
immunologically active cells, acting as a 'sieve'
for antigens carried to it via the portal system.
Functions of liver
Uses of liver function tests
Screening : non-invasive yet sensitive
Pattern of disease : eg - differentiating between acute
viral hepatitis and various cholestatic disorders and
chronic liver disease. (CLD).
Assess severity and predict the outcome .
Follow up : and also helpful in evaluating response to
therapy
Liver function tests in practice
Markers of liver dysfunction
serum bilirubin ( excretory function)
urine bilirubin,urobilinogen and bile salts
Markers of synthetic dysfunction
Total protein, albumin, A/G ratio
Prothrombin time & INR
Detoxification markers
Blood ammonia
Exogeneous dye tests – BSP test
indocyanine green test
Markers of hepatocellular injury
Alanine aminotransferase ( ALT)
Aspartate transaminase (AST)
Alkaline phosphatase
Gamma glutamyl transferase
Leucine aminopeptidase
5’ nucleotidase
Other special tests
Ceruloplasmin ( Wilson’s disease)
Ferritin
Alpha-1-antitrypsin
Alphafetoprotein ( hepatocellular carcinoma)
Immunological tests
Antimitochondrial antibodies ( Pri biliary cirrhosis)
ANCA ( pri sclerosing cholangitis )
Bilirubin
Bilirubin is a breakdown product of haem (a part of
haemoglobin in red blood cells).
The liver is responsible for clearing the blood of
bilirubin.
Reference range : 0.2–0.8 mg/dL
Increased total bilirubin causes jaundice ( levels greater
than 2mg/dl)
Bilirubin ( contd)
Unconjugated (indirect)- insoluble
↑ in hemolysis, Gilbert syndrome
Unconjugated hyperbilirubinemia when >80% of total
bilirubin is unconjugated
Conjugated (direct)- soluble
↑ in obstruction, cholestasis, cirrhosis, hepatitis, primary
biliary cirrhosis, etc.
Conjug hyperbilirubinemia> 50% is conj bilirubin
Methods for bilirubin
1. Van den bergh reaction
2. Jendrassik- grof bilirubin method
3. Dry chemistry slide methods
Methods for determination of serum bilirubin are based on
coupling of bilirubin pigments with diazo compounds to
form azobilirubin
Conjugated bilirubin - immediate colour reaction (direct)
Unconj bili – reaction on addition of alcohol/caffeine
benzoate ( indirect)
Urine bilirubin & urobilinogen
Urine bilirubin : only conjugated bilirubin is excreted in
urine
Urobilinogen:
increased in haemolytic anaemias
Decreased in hepatic diseases
Ref range – 0 – 4 mg/day
Lab determination is based on Ehlrich reaction
using para-dimethyl aminobenzaldehyde to give a red
colour
Bile acid assays
Are the final products of metabolism of cholesterol and
play a role in overall digestion of lipids
Serum concentration are microgram/ml amounts even
after a meal
Increased levels seen in liver diseases
Most helpful in differentiation of hepatobiliary disease
from congenital hyperbilirubinemia or hemolysis.
Lab methods: gas chromatography, Enzymatic methods
or immunoassays
Serum albumin
Albumin is the most significant protein synthesized by the liver and is
an indicator of overall function.
The half-life of albumin is approximately 20 days.
Albumin levels are decreased in chronic liver disease, such as cirrhosis
Normal albumin concentration does not rule out liver disease as an
acute condition may exist
Ref range 3.5 – 5 g/dl
• Poor marker of liver function- decreased by trauma, inflammatory
conditions, malnutrition
Prothrombin time and INR
The liver is responsible for the production of coagulation factors
The prothrombin time is the time it takes plasma to clot after
addition of tissue factor(obtained from animals)
This measures the quality of the extrinsic pathway (greatly
affected by levels of factor VII in the body)
poor factor VII synthesis (due to liver disease) may prolong the
PT.
Normal : 12 – 14 seconds
•.
. The international normalized ratio (INR)
measures the speed of a particular pathway of
coagulation, comparing it to normal
Normal range for a healthy person is 0.9–1.3
high INR level INR=5 high chance of bleeding
The INR will be increased only if the liver is so
damaged that synthesis of vitamin K-dependent
coagulation factors has been impaired;
it is not a sensitive measure of liver function.
It is very important to normalize the INR before
operating on people with liver problems as they
could bleed
Grading Liver Function Using the Child-Turcotte Class
as Modified by Pugh
feature
0
1
Albumin >3.5 g/dl 2.83.5g/dl
Bilirubin <2 mg/dl 2 -3
mg/dl
2
<2.8
g/dl
>3 mg/dl
Prothro < 4 sec
mbin
time
4–6
sec
Ascites None
Controll Refracto
ed
ry
encepha None
lopathy
Controll refractor
ed
y
>6 sec
The Child-Turcotte class, as
modified by Pugh, often known
simply as the "Child class," is
calculated by adding the points
as determined by the patient's
laboratory results: class A=0 to
1; class B=2 to 4; class C=5
and higher.
The classes indicate severity of
liver dysfunction: class A is
associated with a good
prognosis, and class C is
associated with limited life
expectancy
Hepatocellular enzymes
Major diagnostic hepatocellular enzymes are
located at various sites in the hepatocyte giving rise
to different patterns of enzyme release depending on
the cause.
ALT & ASTc – cytosol
Released in membrane injury in viral or toxin
induced hepatitis.
ASTm – mitochondria , alc hepatitis
ALP & GGT – canalicular side of hepatocyte
Bile acids accumulate in cholestasis dissolve memb
fragments and release enzymes into plasma
Transaminases
Located in hepatocytes
Released after hepatocellular injury
2 Forms
AST ---ref range 10 – 35 IU/L
Non-specific to liver: heart, skeletal muscle, blood
ALT ----- ref range 9 – 40 IU/L
More specific
Very high levels ( > 1000) – acute hepatitis
Moderate elevation ( 100-300) – alc hepatitis, wilson’s
disease, nonalcoholic cirrhosis
Mild elevation ( < 100) – chr viral hepatitis
AST:ALT ratio
Elevated in alcoholic disease (2: 1)
AST & ALT assays
There are several variants of assays for
transaminases
In one of them alanine for ALT or aspartate for
AST is added to yield glutamate.
This is then coupled to enzyme glutamate
dehydrogenase ( indicator reaction) yeilding alpha
keto glutarate.
In this reaction NAD is converted to NADH which
is measured as increase in absorbance at 340 nm
Aminotransferases
normal in patients with
cirrhosis.
uncomplicated alcoholic
hepatitis, the AST value is
rarely greater than 500 U per
L and is usually no more
than 200 to 300 U per L.
The highest peak values
are found in patients with
acute ischemic or toxic liver
injury
Alkaline phosphatase
Produced by biliary epithelial cells
Non-specific to liver: bone, intestine, placenta
Elevations
Biliary duct obstruction
Primary biliary cirrhosis
Primary sclerosing cholangitis
Infiltrative liver disease
Highest elevationsI( more than 3 times) represent
obstructive disease
Ref range –30 -120 IU/L
Gammaglutamyl transpeptidase
Among the most sensitive tests in detecting early
hepatobiliary disease
More sensitive marker for cholestatic damage than ALP
may be elevated with even minor, sub-clinical levels of
liver dysfunction.
It can also be helpful in identifying the cause of an
isolated elevation in ALP
Very sensitive in detecting chronic alc liver disease.
Leucine aminopeptidase and 5’nucleotidase
Used to increase the specificity of ALP enzyme for liver
dysfunction.
Not increased in bone diseases.
Lactate dehydrogenase: LD-5 isoenzyme is liver
specific indicates hepatocellular necrosis or metastatic
liver disease.
Detoxification and excretion markers
Ammonia : plasma ammonia concentration reflects
the liver’s ability to detoxify ammonia into urea and
excrete urea.
Mainly elevated in advanced liver disease
Useful in evaluating patients who are comatose or
with altered mental status
Most common lab determination is based on
enzymatic reaction using glutamate
dehydrogenase
Ref range : 15 – 45 µg/dl
Exogeneous dye tests :
Evaluate liver’s ability to transport exogeneous
substances into hepatocyte, metabolize and
finally excrete into bile.
Bromosulphopthalein test –a normally
functioning liver should remove > 95% of dye
in 45 min and retain only 5% in plasma
Determined spectrophotometrically
Indocyanine green test : dye is not
conjugated in the liver almost all of it is
recovered in the bile
Disappearence is direct function of blood flow
Disadv of dye tests : problems associated
with exogeneous substances so infrequently
performed.
Metabolic function tests
Lipid metabolism : hepatic disorders oten cause
derangements in lipoprotein metabolism.
In liver diseases there is deficiency of LCAT
and lipoprotein lipase
Resulting in reduced HDL, altered lipoprotein
distribution and hypertriglyceridemia.
Carbohydrate metabolism:
Glucose , galactose and fructose tolerance test
Limitations
Lack sensitivity:
The LFT may be normal in certain liver
diseases like cirrhosis, non cirrhotic portal fibrosis,
congenital hepatic fibrosis, etc.
Lack specificity :
not specific for any particular disease.
Serum albumin may be decreased in chronic disease
and also in nephrotic syndrome.
Aminotransferases may be raised in cardiac
diseases and hepatic diseases.
Except for serum bile acids the LFT are not
specific for liver diseases and
all the parameters may be elevated for
pathological processes outside the liver.
Thus, we see that LFT have certain advantages as
well as limitations at the same time.
Thus, it is important to view them keeping the
clinical profile of the patient .
Jaundice
Jaundice (also known as icterus) is a yellowish
pigmentation of the skin, the conjunctival membranes
over the sclerae, and other mucous membranes
caused by hyperbilirubinemia (increased levels of
bilirubin in the blood).
Types of jaundice
Increased plasma concentrations of bilirubin (> 2 mg/dL) occurs when
there is an imbalance between its production and excretion
Recognized clinically as jaundice
Prehepatic
Results from excess production of
bilirubin (beyond the livers ability
to conjugate it) following hemolysis
Excess RBC lysis the result of -
autoimmune disease; hemolytic
disease of the newborn
structurally abnormal RBCs
(Sickle cell disease); or breakdown
of extravasated blood
High plasma concentrations of
unconjugated bilirubin (normal
concentration ~0.5 mg/dL)
Hepatic
Impaired uptake,
conjugation, or secretion of
bilirubin
Reflects a generalized liver
(hepatocyte) dysfunction
In this case,
hyperbilirubinemia is usually
accompanied by other
abnormalities in biochemical
markers of liver function
Post hepatic
Caused by an obstruction of the
biliary tree
Plasma bilirubin is conjugated,
and other biliary metabolites, such
as bile acids accumulate in the
plasma
Characterized by pale colored
stools (absence of fecal bilirubin
or urobilin), and dark urine
(increased conjugated bilirubin)
In a complete obstruction, urobilin
is absent from the urine
Neonatal jaundice
Common, particularly in premature infants
Transient (resolves in the first 10 days)
Due to immaturity of the enzymes involved in bilirubin conjugation
High levels of unconjugated bilirubin are toxic to the newborn – due to its
hydrophobicity it can cross the blood-brain barrier and cause kernicterus
Serum levels > 15mg/dl are usually seen
Jaundice within the first 24 hrs of life or which takes longer then 10 days
to resolve is usually pathological and needs to be further investigated
Summary
Individual LFT results are not usually specific to a particular
disease; but the pattern of alteration can be more useful.
Abnormal liver function tests must be interpreted with
regard to clinical context and results of previous tests
levels of derangements in LFTs are not always indicative of
the severity of the disease and clinical context is necessary
to determine the underlying aetiology
Take home message
Despite the development of highly sensitive
laboratory tests, clinical assessment and
judgement remain paramount1