Liver function test
Adi PH, SpPK
Learning Objectives
A. umum : memahami tes laboratoium yang digunakan untuk
pendekatan diagnosa penyakit liver.
B.
1. kapan pasien di curigai penyakit liver? Pemeriksaan apa yang digunakan untuk
memastikannya?
2. menganalisa jenis penyakit liver berdasarkan hasil pemeriksaan laboratorim
Specific:
1. dapat interpretasi hasil pemeriksaan lab berkaitan dengan penyakit liver (jenis,
kronisitasnya dan keparahannya )
2. dapat membuat diagnosa banding pasien dengan hasil pemeriksaan laboratorium
3. dapat mengidentifikasi potensi masalah dalam interpretasi hasil test hati
Review: Liver
The
liver is the largest organ in
the body
It is located below the diaphragm
in the right upper quadrant of the
abdominal cavity and extended
approximately from the right 5th
rib to the lower border of the rib
cage.
The
liver is separated into a
right and left lobe, separated
by the falciform ligament. The
right is much larger than the
left .
Functions of liver
Excretory function: bile pigments, bile
salts and cholesterol are excreted in bile
into intestine.
Metabolic function: liver actively
participates in carbohydrate, lipid,
protein, mineral and vitamin
metabolisms.
Hematological function: liver is also
produces clotting factors like factor V,
VII. Fibrinogen involved in blood
coagulation is also synthesized in liver.
Storage functions: glycogen, vitamins A, D and
B12,and trace element iron are stored in liver.
Protective functions and detoxification:
Ammonia is detoxified to urea. kupffer cells of
liver perform phagocytosis to eliminate foreign
compounds. Liver is responsible for the
metabolism of xenobiotic.
How Do We Tell Someone Has Liver
Disease?
Clues that may lead to a suspicion of liver disease:
Anorexia
Fatigue
Nonspecific Nausea
Vomiting
Mental confusion
Jaundice (yellow eyes)
More specific Dark urine (coca-cola urine)
(late findings) Abdominal swelling; ascites
Peripheral edema; leg swelling
Unfortunately none of these are specific markers of liver disease
and for many patients these are very late findings.
Purpose of Liver Tests
1. Screen for clues to the presence of liver injury/disease
liver cell injury
bile flow/cholestasis
2. Quantitate degree of liver function/dysfunction
quantitative liver tests
3. Diagnose general type of liver disease
pattern of liver test abnormalities
4. Diagnosis of specific liver disease
disease-specific tests such as serology for
viral hepatitis
Tests of Liver Cell
Injury/Death
Transaminases
Alanine amino transferase (ALT)
Aspartate amino transfersase (AST)
Transaminases:
AST(SGOT)
ALT(SGPT)
Many tissues
Liver only
Cytosol/mitochondria
Normal blood levels:
method)
Cytosol
20-70 IU/liter (depending on
Some AST/ALT release occurs normally
Require pyridoxal 5-phosphate as an essential
cofactor
Multi-channel Automated Analysis of Enzymes in Blood
lamp
Patient
serum
ALT
+
substrate
Substrate
Colored
product
Photodetector
Absorbance
converted to
enzyme activity
Release of AST/ALT from Liver Cells
during Acute Hepatocellular Injury
AST
ALT
Transaminases
hy do we used these enzymes to indicate liver damag
1. Convenient to measure
2. Present in liver cells in large amounts
3. Direct release of enzymes into blood through
fenestrated endothelium allows rapid
quantitative assessment of ongoing
hepatocyte necrosis
4. Blood level roughly proportional to the number
of hepatocytes that died recently (hours-days)
Patterns: AST and ALT in Various Liver Diseases
3000
2000
AST
500
Serum
Enzyme
Level
(IU/ml)
200
ALT
100
Acute viral
Acute viral
hepatitis A
hepatitis A
(clinically severe) (clinically mild)
Mild chronic
Cirrhosis
hepatitis C
(little ongoing
(asymptomatic)
injury)
Transaminases
Special considerations:
1. AST is also present in other tissues
(muscle, brain, kidney, intestine).
ALT is more specific for liver.
2. Even very mild liver abnormalities can cause
slightly elevated AST/ALT
- for example, mild fatty liver.
Transaminases
Problems with using transaminases to assess liver
injury:
1. Only assess injury over the past 1-2 days as
enzymes
are cleared efficiently from blood by
RES
2. May not accurately assess hepatocyte death
from apoptosis
3. Magnitude of elevation does not necessarily
correlate
with extent of liver function or
dysfunction at the present time or in the
future.
AST and ALT = rate of destruction of hepatocytes
Transaminases and Alcoholic Liver Disease
Further: Mitochondrial AST and alcohol
Alcohol shifts mAST from mitochondria to
plasma membrane where it readily enters
blood thus AST easier to remove from
hepatocytes.
Therefore: AST>>ALT is released into blood
from damaged hepatocytes
AND
both AST/ALT enzymatic activities in blood
are lower than expected from the extent of liver
damage/dysfunction.
Release of AST/ALT from Liver Cells After Alcohol Exposure
AST
ALT
Alcohol increases mitochondrial AST on liver cell plasma membrane
where it readily enters blood. Thus AST>>ALT in blood.
Patterns: AST versus ALT
1000
Ratio 2.4
Ratio 0.65
Ratio 0.8
650
Serum
Enzyme
Level
(IU/ml)
200
AST
ALT
100
Alcoholic
hepatitis
Acute viral
hepatitis A
Mild chronic
hepatitis C
Tests of Cholestasis/Reduced Bile Flow
Enzymes released as a
Accumulation in liver/blood
consequence of decreased
of substances normally
bile flow
excreted in bile
Alkaline phosphatase
Bilirubin
or
5-nucleotidase
Bile salts
Leucine aminopeptidase
-glutamyl transpeptidase
Alkaline Phosphatase:
Location at Canalicular (Apical)
Membrane
urpose: ? Detoxifies lipopolysaccharide (LPS) from bacteria
Alkaline Phosphatase in Various Liver Diseases
1500
Degree of elevation of AP is highly variable
depending on duration and extent of
cholestasis and other unknown factors.
1000
500
Serum
Enzyme
Level
(IU/ml)
200
100
Long-standing
bile duct
obstruction
Acute bile
duct
obstruction
Mild early
partial
bile duct
obstruction
Hepatocellular
disease
Alkaline Phosphatase
Interpretation of elevated levels:
1. Cholestasis (especially in extrahepatic
obstruction
2. Infiltrative diseases (granulomas)
3. Neoplastic disease infiltrating liver
Sensitive test as will go up if only some small ducts
are obstructed and/or if there is only partial
obstruction of major ducts.
Disadvantages:
Not completely specific because of isoenzymes
in other organs (bone, intestine, placenta)
Ex: bone disease, intestinal obstruction,
pregnancy.
Serum Bilirubin (Bile
Acids)
Rationale:
Liver is virtually the only mechanism for excretion
Cholestasis from any cause results in back-up
of these compounds in blood
Interpretation:
Cholestasis: extrahepatic or intrahepatic
Disadvantages:
Does not distinguish hepatocellular disease,
in which hepatocytes dont make bile,
from bile duct obstruction
Bilirubin
An organic anion
The byproduct of heme breakdown
In mammals bilirubin must be conjugated
to
glucuronic acid and excreted in bile
Blood levels go up if any steps in
production or
hepatocyte excretion are altered.
However
obstruction at the level of bile ducts must
BLOOD
CELLS
Hemoglobin
Globin
Heme
O2
Heme oxygenase
CO
Stercobilin
excreted in feces
Urobilin
excreted in urine
Urobilinogen
formed by bacteria
INTESTINE
Biliverdin IX
reabsorbed
into blood
KIDNEY
via bile duct to intestines
NADPH
Biliverdin
reductase
Bilirubin diglucuronide
(water-soluble)
NADP+
2 UDP-glucuronic acid
Bilirubin
(water-insoluble)
via blood
to the liver
Bilirubin
(water-insoluble)
LIVER
Fig. 2 metabolism of bilirubin
Difference of two bilirubins
indirect
bilirubin
Binding with Glucuronic acid
Reacting with the diazo
reagent
no
direct
bilirubin
yes
Slow and
indirect
Rapid and
direct
small
large
Discharged via kidney
no
yes
Pass through the
membrane of cell
yes
no
solubility in water
2. urine(/faeces)
A. urobilinogen :
Conjugated bilirubin is excreted via bile
salts to intestine. Bacteria in the intestine
break down bilirubin to urobilinogen for
excretion in the feces (normal value for fecal
urobilinogen = 40 - 280 mg/day)
Normally there are mere traces of urobilinogen in the
urine. average is 0.64mg , maximum normal 4mg/24hours.
B. Urobilin
Urobilin is the final product of oxidation of urobilinogen by
oxygen in air. The amount change with the amount of
urobilinogen excretion .
B. bilirubinurine:
Bilirubin is not normally present in urine and faese since
bacteria in intestine reduce it to urobilinogen. The kidneys
do not filter unconjugated bilirubin because of its avid
binding to albumin.
conjugated bilirubin can pass through glomerular filter.
Bilirubin is found in the urine in obstructive jaundice due
to various causes and in cholestasis.
Note:
Bilirubin in the urine may be detected even before clinical
jaundice is noted.
Who is a candidate for the
test?
Bilirubin is used to diagnosis of
jaundice. Abnormal bilirubin levels can
be found in many disorders, including:
blocked bile ducts, cirrhosis, hepatitis
and other liver diseases or immature
liver development in newborns.
Hemolytic Jaundice
Hepatic Jaundice
Obstructive jaundice ( Cholestasis)
Congenital Jaundice
Sample
Indices
Normal
Hemolytic
Jaundice
Hepatic
Jaundice
Obstructive
Jaundice
Serum
Total Bil
1mg/dl
1mg/dl
1mg/dl
1mg/dl
Direct Bil
0
0.8mg/dl
Indirect Bil
1mg/dl
Color
normal
deeper
deep
deep
Bilirubin
Urobilinogen
A little
uncertain
Urobilin
A little
uncertain
Color
normal
deeper
lighter or
normal
Argilous
(complete
obstruction)
Urine
Stool
Hepatic Bilirubin Transport
RBC
breakdown
in RES
Unconj
Bilirubin
SER
UDP-glucuronide
+
Unconj BR
Conj
BR
Unconj BR
Conj
BR
Conj
BR
Blood
Hepatocyte
Bile
Canaliculus
MRP-2:
Multispecific organic
anion transporter
Conjugated bilirubin
Glutathione S-conjugates
other organic anions
Hepatic Bilirubin Transport and Mechanisms
of Hyperbilirubinemia
Gilbert's syndrome (mild)
Crigler-Najjar syndrome (severe)
SER
Hemolysis
Unconj
Bilirubin
Bile
Canaliculus
Unconj BR
Conj
BR
Multispecific organic
anion transporter
Conj
BR
Blood
Conjugated bilirubin
Glutathione S-conjugates
other organic anions
Hepatocyte
Dubin-Johnson syndrome
Rotor's syndrome
?estrogen/cyclosporin
Mechanism of Hyperbilirubinemia
in Liver Disease
SER
UDP-glucuronide
+
Unconj BR
Conj
BR
Unconj
Bilirubin
Unconj BR
Conj
BR
Conj
BR
Albumin
Overall
Rate-Limiting
Step
Interpretation of Elevated Serum Bilirubin
Conjugated hyperbilirubinemia:
BR reached liver and was conjugated but not excreted in bile
1. Cholestasis/biliary obstruction (must be essentially complete)
2. Hepatocellular damage (collateral damage to all liver functions)
bile formation impaired >> conjugation impaired
3. Rare disorders of canalicular secretion of conjugated bilirubin
Unconjugated hyperbilirubinemia:
BR didn't reach liver efficiently or wasn't conjugated
1. Massive overproduction - acute hemolysis
2. Impaired conjugation
common: Gilbert's syndrome (mild)
rare:
Crigler-Najjar syndrome (severe)
Further: Bilirubin Undergoes Non-Enzymatic Reaction
with Albumin
Formation of Bilirubin-Albumin Conjugates
Bili-albumin conjugate
or "delta bilirubin"
Blood
Alb
BR-Glu
Hepatocyte
ER
Alb
BR
BR
BR
BR-Glu
BR-Glu
BR-Glu
Bile
Why is Bili-Albumin of Clinical
Interest?
Not of interest during liver disease as this form
of bilirubin is measured as conjugated bilirubin.
However, after resolution of cholestasis/liver
disease, bili-albumin is cleared like albumin
Albumin half-life:
several weeks
Conj. bilirubin half-life:
hours to days
Thus resolution of jaundice is often SLOW
compared to improvement of other liver
functions.
Purpose of Liver Tests
1. Screen for clues to the presence of liver injury/disease
liver cell injury
bile flow/cholestasis
2. Quantitate degree of liver function/dysfunction
quantitative liver tests
3. Diagnose general type of liver disease
pattern of liver test abnormalities
4. Diagnosis of specific liver disease
disease-specific tests such as serology for
viral hepatitis
TESTS OF LIVER FUNCTION
Blood Level
Production
Albumin
Clotting factors
Blood Level
Bilirubin
Bile Acids
Elimination
Metabolism
C-Aminopyrine
14
Metabolites
CO2
14
Albumin
Rationale
Liver is the sole source
Interpretation of Decreased Level
Decreased liver production
Increased renal/GI loss (nephrotic syndrome;
protein losing enteropathy in inflammatory
bowel disease
Protein malnutrition
Disadvantages
Prolonged half-life
No unique interpretation
Prothrombin Time
Rationale
Liver is sole source of vitamin K-dependent
clotting factors, including those critical for PT
Factor VII has very short half-life (hours)
Interpretation of Increased PT
Hepatocyte protein synthesis impaired
Vitamin K deficiency/Coumadin therapy
Disseminated intravascular coagulopathy
Advantages
Rapidly reflects changes in liver function
Interpretation of Abnormal
Albumin/Prothrombin Time
Liver markedly diseased - reserve function gone
Albumin:monitors slow changes in liver function
(months to years)
reflects long-term liver dysfunction
Protime: monitors rapid changes in liver function
(hours to days/weeks)
reflects either short or long-term liver
dysfunction
Other Clues to Globally Impaired Liver Function
Bilirubin:goes up with any disease that globally
impairs
liver function (OR blocks bile flow)
Glucose: hypoglycemia (late finding; indicates
very poor liver function)
BUN:
low BUN is a late and poorly specific finding
in liver dysfunction due to poor urea
synthesis
Purpose of Liver Tests
1. Screen for clues to the presence of liver injury/disease
liver cell injury
bile flow/cholestasis
2. Quantitate degree of liver function/dysfunction
quantitative liver tests
3. Diagnose general type of liver disease
pattern of liver test abnormalities
4. Diagnosis of specific liver disease
disease-specific tests such as serology for
viral hepatitis
Interpretation of Liver Tests
A. Consider nonhepatic causes of abnormal liver
tests
B. Examine the pattern of liver test abnormalities
to
categorize liver disease:
1. cholestatic
2. acute
versus
versus
3. decompensated
function
hepatocellular
chronic
versus mild functional
impairment
Patterns of Abnormal Liver Tests
Hepatocellular
Major:
AST/ALT
Cholestasis
Alkaline Phosphatase
Minor:
Bilirubin
Bilirubin
PT/albumin
AST/ALT
PT (Vit K deficiency)
Patterns: Acute Liver Disease
20
Hepatocellular disease
Cholestatic disease
Fold
Increase
10
2
1
AST or ALT
Alkaline
Phosphatase
Bilirubin
PT
Clues to Acute vs Chronic Liver Disease
Abnormalities of PT versus albumin
Known duration of abnormal liver tests
History of exposure to potential causative agents
Clinical signs of consequences of long-standing liver disease
Tempo of subsequent changes in AST/ALT, bilirubin, PT
chronic tends to change slowly
acute tends to change quickly
20
Patterns: Chronic Liver Disease with Impaired Liver Function
Fold
Increase
10
2
1
Albumin
AST or ALT
-2
Alkaline
Phosphatase
Bilirubin
PT
Clues to Severity of Liver Dysfunction
Prothrombin time
Albumin
(Bilirubin, glucose)
(Clinical signs of consequences
of severe liver dysfunction such
as hepatic encephalopathy)
Clues to severity
of liver damage
and, potentially, to
severity of liver
dysfunction may
come from the
temporal sequence
of changes in
readily available liver
tests.
For example, rapid
fall in AST/ALT
in severe hepatitis
may not be a good
sign.
Purpose of Liver Tests
1. Screen for clues to the presence of liver injury/disease
liver cell injury
bile flow/cholestasis
2. Quantitate degree of liver function/dysfunction
quantitative liver tests
3. Diagnose general type of liver disease
pattern of liver test abnormalities
4. Diagnosis of specific liver disease
disease-specific tests such as serology for
viral hepatitis
These are discussed in future lectures
Summary
Use biochemical tests to assess
Presence of liver disease
General type of liver disease
Sense of severity of liver dysfunction
Sense of acute versus chronic disease
Use liver tests with other data to work
through differential diagnosis
See algorithms in syllabus and textbook