LIVER FUNCTION TESTS

AND LIVER DISEASES

Prof. Fang Zheng
Department of Laboratory
Medicine
School of Medicine, Wuhan
University
 Content

 Anatomy of Liver
 Functions of Liver
 Tests of Liver Function
 Liver Diseases
 How to use biochemical tests of
liver functions?
 INTRODUCTION
• The liver is divided into four
lobes.
THE STRUCTURE
OF LIVER
 LOBES VASCULAR
AND
BILIARY SYSTEMS
 The portal vein carries blood that has
already passed through the capillary bed
of the gastrointestinal tract.

 The hepatic artery carries well-

oxygenated blood to the liver.

 Both circulations mix in a vast network of

hepatic sinusoids and leave the liver via
the hepatic vein. Sinusoids are lined by
endothelial and Kupffer’s cells.
 LOBES VASCULAR AND
BILIARY SYSTEMS
•In the liver the ductules merge into bile
ducts, hepatic ducts, and eventually the
common hepatic ducts.

•Their bile drains into the right and left

hepatic ducts.
 Liver Function
1. Synthesis secretion
plasma proteins,
bile
2. Metabolism of
carbohydrate
lipid, protein
vitamins, hormone
bile acids, bile
pigment, drug and
toxins
3. Detoxification
(bio-
transformation)
 TESTS OF LIVER
FUNCTION

1.Tests of Protein Metabolism

2. Tests of Bilirublin Metabolism
3. Dye intake and Excretion
4. Biochemical Serum Enzyme Tests
5. Tests of Viral Hepatitis
6. Other tests
 Tests of Protein
Metabolism

1. Serum total protein (TP), albumin (A) and

globulin (G)

2. Serum protein electrophoresis

3. Hepatic neoplasm markers

 Serum total protein (TP),
albumin (A) and globulin
(G)
Albumin
Albumin is quantitatively the most important
plasma protein synthesized by the liver and thus
is a useful indicator of hepatic function. Albumin
has a fairly long half-life in serum (20 days) and
hence is not a good indicator of hepatic protein
synthesis in acute liver disease.
Serum albumin levels are depressed in
alcoholic cirrhosis.
A crude measure of the liver’s synthetic
capacity

hypoalbuminaemia: advanced chronic liver

 Serum total protein (TP),
albumin (A) and globulin
(G)
 Globulin: The main proteins in
serum.
 Total serum globin: the
severity of liver disease
 Reference
Value

 Alb 40-55g/L
 TP 60-80g/L
 Globulin 20-30g/L
Serum protein
electrophoresis

Densitometric scan of a normal serum protein

electrophoresis pattern showing the relative position of
the albumin,α1,α2,β and γregions
 Hepatic neoplasm
markers

 alpha-fetoprotein(AFP): primary
hepatocellular carcinoma
 Carcinoembryonic antigen(CEA): ↑liver
metastatic carcinoma or other carcinomas of
the gastrointestinal system.
 Reference Value
(AFP)

Normal < 25ng/mL

Hepatitis 25~200ng/mL

carcinoma >400ng/mL
 OTHER SERUM
PROTEINS
PRODUCED BY THE
LIVER
Coagulation factors (prothrombin time )

1) The liver synthesizes six coagulation factors:

factors(fibrinogen),II(prothrombin),V,VII,and X.
Only substantial impairment in the liver’s ability to
synthesize these proteins can result in clotting
abnormalities

2) Prolongation of the prothrombin time is not specific

for liver disease.
Tests of Bilirublin
Metabolism
 Serum total bilirubin(STB)
 Conjugated bilirubin
 Urobilinogen
 Bilirubin
Metabolism
1) Bilirubin is the principal degradation product of
heme.

2) Bilirubin transport and conjugation in the

hepatocyte.

3) The generally accepted reference range for normal

plasma bilirubin concentrations in healthy persons,
which includes 95 per cent of all individuals’ values,
is 1.7 to 17.1umol/L.
Bilirubin
metabolis
m
 Bilirubin
Bilirubin is derived from the tetrapyrrole
prosthetic group found in haemoglobin and the
cytochrome. It is normally conjugated with
glucuronic acid to make it more soluble, and
excreted in the bile.
Both conjugated bilirubin and unconjugated
bilirubin may be present in plasma. Conjugated
bilirubin is water soluble, unconjugated bilirubin
is not, and binds to albumin. Bilirubin is
neurotoxic, and if its levels rise too high in
neonates, permanent brain damage can occur.
 BILIRUBIN
Bilirubin metabolites are responsible for the brown
coloration of faeces. If bilirubin does not reach the
gut, stools become pale in color.

Bilirubin in the gut is metabolized by bacteria to

produce stercobilinogen, which is partly
reabsorbed and reexcreted in the urine as
urobilinogen. When high levels of conjugated
bilirubin are being excreted , urine may be a deep
orange colour.
 High bilirubin level
•Haemolysis (Haemolytic)The increased haemoglobin
breakdown produces bilirubin which overloads the
conjugating mechanism.
Unconjugated hyperbilirubinaemia is commonly
encountered in babies.
•Liver disorder (Hepatocellular) Failure of the
conjugating mechanism within the hepatocyte.
•Obstruction in the biliary system
(Cholestatic)
including extrahepatic biliary obstruction, Intrahepatic
biliary obstruction is much more difficult to diagnose
 Jaundice
 What’s Jaundice?
Jaundice is a yellow discoloration of the
skin or sclera.
Due to the bilirubin concentration in plasma
is much greater than normal (greater than
about 40 µ mol/L)
Causes of
jaundice
 Jaundice indicates that there is an elevated
concentration of bilirubin in serum.
 In neonates it is important to determine the
concentration of unconjugated bilirubin in order to
decide what treatment is required.
 In adults, the most common cause of jaundice is
obstruction, and this is confirmed by the elevation of
both bilirubin and alkaline phosphatase
 Serum
bilirubin
 Jaundice/More than
34.2µ mol/L(2.0mg/100mL)
 Latent jaundice /17.2 ～ 34.2 µ mol/L
 Normal/ Less than 1.70~17.2 µ mol/L
 80% is unconjugated bilirubin and
20% is conjugated bilirubin
 Urine Bilirubin
 Because only conjugated bilirubin is excreted in
urine, it is indirect test for increased concentration
of conjugated bilirubin in serum.
 A fresh urine specimen is required since bilirubin is
very unstable when exposed in light and room
temperature.
 The chemstrip test for bilirubin in urine.
 Haemolytic Cholestatic Hepatocellular

Featur 1.Bilirubin 1.Bilirubin maybe 1.AST+ALT ↑ ↑

es usually< ↑↑↑ 2.Bilirubin ↑ later
75µ mol/l. 2.Bilirubin in 3.Bilirubin in
2.No bilirubin in urine urine
urine. 3.ALP Usually>3× 4. ALP↑ later
3.Reticulocytosis upper limit of
4.haemoglobin↓ reference range.
5. 4.AST, ALT+LDH
haptoglobin↓( 触 usually modestly
珠蛋白 ) ↑
6. LDH may↑
DIFFERENTIAL DIAGNOSIS OF JAUNDICE

Unconjugated hyperbilirubinemia
Increased heme catabolism
Hemolytic anemia
Hematoma
Impaired hepatic conjugation
Neonatal jaundice

Conjugated hyperbilirubinemia
Impaired hepatic excretion
Hepatocellular disease
Posthepatic obstruction
Dye intake and
Excretion
 Indocyanine green retention rate
(ICGR): 15min<10%
 Chronic hepatitis: 15-20%
 Cirrhosis: 35%
 SERUM ENZYME
TESTS
Aminotransferase
1) AST (Aspartate) and ALT (Alanine) is present in a wide
variety of tissues-including heart, skeletal muscle, kidney,
and brain in addition to liver.

2) Serum levels of AST and ALT are elevated to some extent

in almost all liver diseases (viral hepatitis, obstructive
jaundice and liver cirrhosis).

3) The elevations of the enzyme levels do not correlate with

eventual outcome, even though they may reflect the extent
of hepatocellular necrosis.
 SERUM ENZYME
TESTS
Aminotransferase

Clinical value of AST and ALT

The ratio of AST to ALT

Reference Value
AST and ALT: 5~40U/L
 SERUM ENZYME
TESTS
MARKERS OF CHOLESTASIS ——Alkaline
phosphatase (ALP)
An indices of a blockage of bile flow Cholestasis,
which maybe intra- or extra-hepatic disease
(tumor, cirrhosis )
ADULT 25~90U/L
CHILD 50~350U/L
 Plasma alkaline phosphatase activity as a function of age and
sex(—men ； …… , women). Horizontal lines refer to multiples of
the adult upper reference limit.
 SERUM ENZYME
TESTS
1) The reference range for ALP is dependent on
age.

2) In the human body, ALP has been identified

in liver, bone, intestine, kidney and
leukocytes. ALPs are a heterogeneous group
of enzymes. For patients with high ALP levels,
measurement of ALP isoenzymes is useful for
differentiating between bone and liver
sources.

3) The highest elevations of ALP in patients with

liver disease occur in patients with
cholestasis or hepatic carcinoma.
 SERUM ENZYME
TESTS
γ -Glutamyl Transpeptidase ( γ -GT)
Cholestasis
Alcohol
Drugs
Acute hepatic damage
Combining with alkaline phosphatase

Male 11-50U/L
Female 7~32U/L
 SERUM ENZYME
TESTS
1) γ -GT has been localized to the whole hepatobiliary tree-
from hepatocytes to common bile duct in the liver, and
also to pancreatic acini and ductules.

2) Serum γ -GT is elevated in association with a wide variety

of pathologic states in addition to hepatobiliary disease,
including chronic alcoholism, pancreatic disease,
myocardial infarction, renal failure, chronic obstructive
pulmonary disease and diabetes.

3) In liver disease, serum γ -GT activity correlates well

with serum ALP, and is the most sensitive indicator of
biliary tract disease.
 SERUM ENZYME
TESTS
5’-Nucleotidase (5’-NT)

1) 5’-NT is present in the intestines, brain, heart, blood

vessels and endocrine pancreas in addition to the liver.

2) Elevation of 5’-NT in the serum are purported to be of

hepatobiliary origin only despite the widespread localization
of the enzyme in other body tissues.

3) In clinical hepatic disease, serum 5’-NT correlate closely

with serum alkaline phosphatase.

4) Serum 5’-NT is particularly useful in diagnosing liver

disease in childhood and in pregnancy.
 SERUM ENZYME
TESTS
 monoamine oxidase, MAO
 Β-Proline hydroxylase, PH

Indices of hepatic fibrosis

● Unlike some disorders such as acute
pancreatitis (Amylase) and myocardial
infarction (Myoglobin Troponin), for
which there are enzyme markers that
are primarily used for one disorder and
have high diagnostic efficiencies, there
are no enzyme markers that are
specific for any single liver disease.
● When evaluating these disorders,
therefore, it is appropriate to consider
a panel of markers, sometimes called
live function tests (LFTs).
● usually includes bilirubin, AST, ALT,
ALP, and sometimes GGT and 5'NT
● although these tests can reflect
various disease processes in the liver,
they do not reflect hepatic reserve for
synthesis and metabolic functions
Other tests for Liver
Excretion Function
 Bile Acids
 Bile Acids
The regulation of bile acid is a major function
of the liver. Cholesterol homeostasis is in large
part maintained by the conversation of cholesterol
to bile acids and subsequent regulation of bile
acid metabolism.

Bile acid provides surface-active detergent

molecules that facilitate both hepatic excretion of
cholesterol to bile acids and solubilization of lipids
for intestinal absorption.
The metabolism of bile acid
 The clinical
Significances of SERUM
BILE ACIDS
1. In the last 20 years, there have been major
methodological advances in the
measurement of serum bile acids.
2. Clinical significance:
1) Bile acids more specifically reflect excretory
function. Increase of bile acids in serum suggest
impaired hepatic uptake or secretion, or portal-
systemic shunting
2) The high concentration of serum bile acids
seem to occur in viral hepatitis and extrahepatic
obstruction.
 SERUM BILE
ACIDS
3) Abnormal results of ALP, AST and rGT lacked the
specificity of bile acids abnormalities. AST
determinations are more sensitive than those for
fasting serum bile acids in detecting mild liver
diseases such as fatty liver or chronic persistent
hepatitis, because mild or patchy hepatocellular
injury does not impair hepatic function severely.

4) The ratio of cholic acid to chenodeoxycholic acid is

between 0.5-1.0 in healthy subjects, but in
extrahepatic obstruction it is increased 0.96-3.6.
 SERUM BILE ACIDS

 Reference value:
Total Bile Acid ： 0~6µ mol/L
 Summary of Liver function
tests
•A request for LFTs will usually generate results
for bilirubin, the aminotransferases and alkaline
phosphatase.
• Raised activities of the aminotransferases(AST
and ALT) indicate hepatocellular damage.
•Increased bilirubin concentration and increased
alkaline phosphatase activity indicate the presence
of cholestasis, a blockage in bile flow.
•Serial use of LFTs is of most value in following the
progress or resolution of liver disease.
•Measurement of γ GT can give an indication of
hepatocellular enzyme induction due to drugs or
Tests of Viral Hepatitis
 Hepatitis A
 Hepatitis B
 Hepatitis C
Tests of Viral Hepatitis
A
 Hepatitis A(HAV) is a kind of RNA
virus. It is transmitted by the fecal-
oral route. It is thus implicated in
most instances of water-borne and
food-transmitted infection and in
epidemics of viral hepatitis.
 Serologic markers of viral
hepatitis A
Agent markersdefinition significances

HAV Anti- Antibody Current or recent

HAV to HAV infection of HAV
IgM
type
IgG Current or
type previous
infection of HAV,
confers immunity
 Tests of Viral Hepatitis
B
 HBV is a kind of DNA virus
consisted by core and surface
components. HBV transmission
occurs most commonly via blood
and blood products,
contaminated needles and
intimate personal contact. HBV is
present in all body fluids.
Serologic markers of viral
hepatitis
Agent markers definition significances

HBV HBsAG HBV surface Positive in acute or chronic

antigen infection

HBeAG e antigen, a Transiently positive in acute

component hepatitis B, reflects presence of
viral replication and high
infectivity
Anti-HBe Antibody to Transiently positive, may be
e antigen persistently present in chronic
cases, reflects low infectivity
Anti-HBc IgG type Positive in all acute and chronic
Antibody cases, reliable marker of infection
to core past or current
antigen
Agent markers definition significances
Anti-HBs Antibody to confers immunity,
surface
Tests of Viral Hepatitis
C

• HCV is a kind of RNA virus and

is similar to HBV, is largely
parenterally transmitted. HCV is
the main cause of post-
transfusion hepatitis.
 Serologic markers of viral
hepatitis
Agent markers definition significances

HCV Anti- Antibody Positive after clinical

HCV to HCV onset(15 weeks),
Not protective,
Persists in chronic
infection
Liver
Disease
Causes
Poisoning for liver
disease
Infection Viral hepatitis (hepatitis
B)
Inadequate perfusion
Chronic excess alcohol ingestion
Autoimmune disease
Unusual cause of cirrhosis:
α 1-antitrypsin deficient and
Wilson’s disease
 Liver disease
•Acute Hepatocellular Injury
Viral Hepatitis
Acute Liver failure
•Cholestatic Liver Disease
Intrahepatic Obstruction
Extrahepatic Obstruction
•Chronic Liver Disease
Chronic Hepatitis
Cirrhosis
Liver Cancer
•Alcoholic Liver Disease
Fatty Liver
Alcoholic Hepatitis
 Acute Hepatocellular Injury

It may resolve
OUTCOME
It may progress to acute hepatic
failure
It may lead to chronic hepatic
damage
Biochemic
al findings
in hepatic
failure
 Cholestasis
 Cholestasis represents the
demonstrable accumulation in the
blood stream of substances normally
excreted in bile (e.g., bilirubin,
cholesterol, bile acids).
Cholestatic Liver
Disease
 Intrahepatic Obstruction
Intrahepatic cholestasis often results
from cirrhosis or hepatitis.
 Extrahepatic Obstruction
Extrahepatic cholestasis is usually
the result of mechanical obstruction
of the common bile duct or hepatic
duct.
Chronic Liver Disease
 Chronic Hepatitis
chronic active hepatitis
chronic persistent hepatitis
 Cirrhosis
Liver enzyme levels in cirrhosis are variably
elevated and can be normal during the terminal
stages of the disease.
Primary biliary cirrhosis /Elevations in ALP
and aminotransferases are expected along with
high titers of antimitochondrial antibody.
 Liver Cancer
The liver enzyme results tend to be more
elevated in the active form; however,
differentiation is best made by performing a
liver biopsy.
 Fibrosis of Liver
tissues
Fibrosis is common to several chronic
liver diseases and as such is the
leading cause of morbidity and
mortality from hepatic disease.

Hepatic fibrosis may have biologic

effects on cells as well as physical
effects on blood flow and is a main
cause of portal hypertension.
 Cirrhosis
•The most common causes of cirrhosis are
chronic excess alcohol ingestion, viral hepatitis
and autoimmune diseases.
•Cirrhosis is not reversible. There are no good
biochemical indicators of cirrhosis in the early
and stable period
•Cirrhosis can develop in children as a result of
a1-antitrypsin deficiency or Wilson’s disease
and in adult due to haemochromatosis.
 Terminal stage of
cirrhosis
•Developing
jaundice
•Encephalopathy
•Ascites
•Bleeding
tendenices
•Terminal liver
failure
 Alcoholic Liver Disease
Fatty Liver
The concentrations of traditional liver
enzymes are typically within the normal
range. Definitive diagnosis is made by a
liver biopsy. The disease is considered
benign and can be effectively reversed by
immediate abstinence from ethanol intake.
Alcoholic Hepatitis
Liver enzyme concentrations are increased,
notably AST and ALT
Normal
Liver
 Fatty
Liver
Cirrhotic Liver
 Case history
 A 49-year-old woman attend her GP with an 8-day
history of anorexia, nausea and flu-like symptom.
She had noticed that her urine had been dark in
colour over the past 2 days. Physical examination
revealed tenderness in the right upper quadrant of
the abdomen. LFTS were as follows:
Bilirubin AST ALT ALP γ -GT TP Alb
mol/L U/L (g/L)
63 936 2700 410 312 68 42
Comment on these results.
What is the differential diagnosis?
Markers For Liver Function And
Disease
 Markers For Liver Function And Disease
Disease or function Markers
Function evaluation
Normal synthesis capacity Albumin, prealbumin prothrombin
time,
Excretory function Bilirubin, bile acids , globulins
Metabolic function Ammonia, amino acids, lipids,
serum
protein electrophoresis

Pathological evaluation
Hepatocellular injury AST, ALT
Obstruction Bilirubin, alkaline phosphatase, γ-

GT , 5 ’- nucleotidose
bile acids,
Infections
Viral and autoimmune serologies
Malignancies CEA, α-fetoprotein
 ALT and AST in acute liver
injury
disease enzyme marker

acute hepatitis ALT and AST elevated>1000U/L

(viral or toxic)

HAV ALT elevated in 3 to 4 weeks after infection

ALT return to normal within 8 to 12 weeks
HBV preclinical incubation phase is longer and ALT
and and AST may remain normal for 2 to 6months
HCV ALT and AST return to normal within 2 to 3months
chronic active
hepatitis ALT and AST elevated 5 to10 fold

end-stage ALT and AST return to normal or subnormal

liver disease
Relationship of AST and ALT
to ALP and GGT in Hepatitis
Relationship of AST and ALT to
ALP and GGT in Cholestasis
l pi tl u M
 The best markers for intrahepatic and
extrahepatic cholestasis are ALP, GGT, and 5'NT

 AST and ALT are generally only slightly elevated

in cholestasis, rarely more than 500 U/L.

 The largest elevations (four- to 10-fold) of ALP

are typically seen in obstruction owing to
gallstones or malignancy and in biliary
cirrhosis.

 Measurement of total and direct bilirubin

are also important in making the diagnosis
of obstructive jaundice.
Ratio (AST/ALT)
 The Ratio of (AST/ALT)
 Further differentiation of specific liver

diseases is aided by calculating the ratio

of AST to ALT levels.
— acute or chronic ?
— intra- or extrahepatic ?

 recommended by the International

Federation of Clinical Chemistry (IFCC)

 The ratio is normally approximately 1.15

ALT versus AST levels
in various liver diseases
 AST/ALT
Disease AST/ALT

Acute disorders of the liver <1.0

acute hepatitis
Chronic disorders of the liver >1.0
alcoholic liver disease
chronic active hepatitis
Chronic persistent hepatitis normal
Extrahepatic obstruction
acute passage of a stone ＜ 1.5
intrahepatic cholestasis
biliary cirrhosis and malignancy ≥1.5
Relationship of AST and ALT to ALP
and GGT in Malignancy
o seil pi tl u M
 Relationship of AST and ALT to ALP
and GGT in Alcoholic Live Disease
seil pi tl u M
 Abnormal Liver Function
Tests

Hepatocellular Cholestatic Disease

Disease
Normal Decrease Normal Decreased
Albumin d Albumi Albumin
Albumin n
Acute Chronic Acute Chronic
Hepatitis Hepatitis Cholestasi Cholestasis
s

Ultrasound
Detection

Intrahepatic Extrahepatic
Cholestasis Cholestasis
 Case history
A 60-years-old female with a history of breast
carcinoma treated by mastectomy three years
previously is now complaining of general malaise and
bone pain. Biochemistry showed that fluid and
electrolyte, total protein, albumin and calcium values
were all normal. LFTs were as follows:
Bilirubin AST ALT Alkaline phosphatase γ
GT
µ mol/l U/l
7 33 38 890
32
 Summary

 Biochemical monitoring of liver disease is by

sequential measurements of the aminotransferase,
bilirubin and alkaline phosphatase.
 In acute liver damage there is usually intrahepatic
obstruction as well as hepatocellular damage.
 Severe cases of acute liver damage may progress to
hepatocellalur failure.
 Cirrhosis is the end point of both acute and chronic
liver damage, as well as being caused by a number of
metabolic and autoimmune diseases.
 Biochemical tests may be of little value in making a
specific diagnosis. A liver biopsy is frequently more
helpful.
 The clinical significances of each
liver function test?
 The differentiation diagnosis of
jaundice.
 The evaluations of biochemical tests
of liver functions in different liver
diseases.
Thank You for
Your
Attention!