Plaza, George Carr G.

– Liver Function – Assignment

A. Outline the metabolism of bilirubin from the breakdown of red blood cells up to
bilirubin excretion. This should not be exactly similar with what’s found in the book.

B. Tabulate the differences of unconjugated bilirubin and conjugated bilirubin.

Point of Bilirubin 1 Bilirubin 2
Difference
Definition Unconjugated bilirubin- Not Conjugated bilirubin-conjugated
conjugated in the liver with glucuronic acid in the liver to
form bilirubin diglucuronide
Other -Hemobilirubin (bilirubin as the - Cholebilirubin (Bilirubin formed in
Name product of RBC breakdown; the liver’ passes through in the
directly produced from bile)
hemoglobin) - Post-hepatic bilirubin/ Hepatic
- Pre-hepatic bilirubin (does not Bilirubin (bilirubin
reach in the liver to be formed/conjugated in the liver)
conjugated)
Solubility Insoluble in water Soluble in water
Soluble in fat and alcohol Insoluble in fat and alcohol
Polarity Non-polar bilirubin Polar bilirubin
Plaza, George Carr G. – Liver Function – Assignment

Van den Indirect reacting (Slow reacting)
Berg - reacts slowly with the diazo
Reaction reagent as the central carbon
bridge of bilirubin is buried within
the hydrogen bonds
Toxicity Can cause kernicterus (as a result
of accumulation of unconjugated
bilirubin in the brain)
Diseases Pre-hepatic Jaundice
Gilbert’s Disease
Crigler-Najjar syndrome
Jaundice of newborn
Direct reacting (Prompt bilirubin)
- reacts rapidly even the absence
of accelerators (lack of hydrogen
bonds)
Not toxic to the tissues (does not
bind significantly to neural tissue)
Dubin-Johnson Syndrome
Rotor’s syndrome

C. Tabulate the disorders causing jaundice and indicate the levels of total bilirubin,
conjugated bilirubin, and unconjugated bilirubin for each disorder.

Type of Jaundice Serum Total Serum Serum

Bilirubin Conjugated Unconjugated
Bilirubin Bilirubin
Pre-hepatic INCREASE NORMAL INCREASE
Hepatic
Gilbert’s disease INCREASE NORMAL INCREASE
Crigler-Najjar INCREASE DECREASE INCREASE
syndrome
Dubin-Johnson INCREASE INCREASE NORMAL
Rotor’s syndrome INCREASE INCREASE NORMAL
Jaundice of Newborn INCREASE NORMAL INCREASE
Posthepatic Newborn INCREASE INCREASE INCREASE

D. Create a short summary notes for the other diseases affecting liver function.
Jaundice
 comes from the French word jaune”, which means “yellow”
 Also termed as icterus,
 is used to describe the yellow discoloration of the skin, eyes, and mucous
membranes most often resulting from the retention of bilirubin
 Icterus - most commonly used in the clinical laboratory to refer to a
serum or plasma sample with a yellow discoloration due to an elevated
bilirubin level
 Most commonly classified based on the site of the disorder:
 Prehepatic
 Occurs when the problem causing the jaundice occurs prior to liver
metabolism
 Caused by an increased amount of bilirubin being presented to the
liver
 Seen in acute and chronic hemolytic anemias
 May also be referred to as unconjugated hyperbilirubinemia
 Increased levels of unconjugated bilirubin
Plaza, George Carr G. – Liver Function – Assignment

 Hepatic
 occurs when the primary problem causing the jaundice resides in
the liver (intrinsic liver defect or disease)
 due to disorders of bilirubin metabolism and transport defects
 due to diseases resulting in hepatocellular injury or destruction
 Hepatic causes in increased levels of UNCONJUGATED
bilirubin
 Gilbert’s disease
 Benign autosomal recessive hereditary disorder
 Results from a genetic mutation in the gene (UGT1A1)
(located on the chromosome 2) that produces UDPGT
 Most common cause of jaundice
 characterized by intermittent unconjugated
hyperbilirubinemia, underlying liver disease due to a
defective conjugation system in the absence of hemolysis
 UGT1A1 (the hepatic 1A1 isoform of UDPGT) contributes
substantially to the process of conjugating bilirubin
 UGT1A1 promoter contains the sequence (TA)6TAA
 The insertion of an extra TA in the sequence, as seen in
Gilbert’s syndrome,reduces the expression of the
UGT1A1
 Crigler-Najjar syndrome
 a syndrome of chronic nonhemolytic unconjugated
hyperbilirubinemia
 an inherited disorder of bilirubin metabolism
 A molecular defect within the gene involved with bilirubin
conjugation
 Rare and more serious disorder than Gilbert’s disease
 Have two types:
 Type 1: Complete absence of enzymatic bilirubin
conjugation
 Type 2: Mutation causing a severe deficiency of the
enzyme for bilirubin conjugation
 Physiologic jaundice of the newborn
 deficiency in the enzyme glucuronyl transferase
 results in the rapid buildup of unconjugated bilirubin
 Build up --> deposited in the nuclei of brain and
degenerate nerve cells --> KERNICTERUS
 Kernicterus --> results in cell damage and death
 Treatments:
 Phototherapy
 Destroy bilirubin as it passes through the capillaries
of the skin
 Relatively inexpensive and noninvasive method
thorugh PHOTO OXIDATION
 Conventional phototherapy uses halogen or
fluorescent lights
Plaza, George Carr G. – Liver Function – Assignment

 Transform bilirubin into water-soluble isomers

that can be eliminated without conjugation
 The baby is undressed/ His/her eyes are covered to
protect the nerve layer at the retina
 Fiberoptic phototherapy uses blanket (“bili-
blanket”) that consists of a pad of woven fibers used
to transport light from a light source to the baby’s
back
 The light generated in the bili-blanket breaks
down the bilirubin (photo oxidation)
 Dose of phototherapy (key factor)
 Determined by”: wavelength of the light,
intensity of the light (irradiance), distance
between the light and the baby & body
surface area exposed to the light
 Blood transfusion (extreme cases of
hyperbilirubinemia)
 Second-line treatment when phototherapy fails
 Removing aliquots of blood and replacing it with
donor blood in order to remove abnormal blood
components/ circulating toxins (while blood volume
is maintained)
 Approximately 20mg/dl of UNCONJUGATED bilirubin is
considered dangerous high level for this condition and should
be monitored and treated appropriately

 Hepatic causes in increased levels of CONJUGATED bilirubin

 Dubin-Johnson syndrome
 Rare autosomal recessive inherited disorder
 caused by a deficiency of the canalicular multidrug
resistance/multispecific organic anionic transporter protein
(MDR2/cMOAT)
 Defective removal of conjugated bilirubin from the liver cell
and the excretion into the bile
 Accumulation of CONJUGATED bilirubin
 Obstructive --> Increased levels of DELTA bilirubin
(conjugated bilirubin circulates bound to albumin)
 Delta bilirubin fraction reacts as conjugated bilirubin
in the laboratory method to measure conjugated or
direct bilirubin
 Appearance of dark-stained granules (thought to be
pigmented lysosomes) on a liver biopsy sample
(DISTINGUISHING FEATURE)
 Relatively mild in nature with an excellent prognosis
 No treatment is necessary (patients have normal
expectancy)
 Rotor’s syndrome
 Clinically similar to Dubin-Johnson syndrome
Plaza, George Carr G. – Liver Function – Assignment

 UNKNOWN ETIOLOGY
 hypothesized to be due to a reduction in the
concentration or activity of intracellular binding proteins
such as ligandin
 Does not show dark pigmented granules in liver biopsy
 Relatively benign --> excellent prognosis
 Posthepatic jaundice
 Results from biliary obstructive disease, usually from physical
obstructions (gallstones or tumors)
 Bilirubin is effectively conjugated; however, it is unable to be
properly excreted from the liver

Cirrhosis
 A clinical condition in which scar tissue replaces normal, healthy liver tissue
 Blocks the flow of blood through the organ and prevents the liver from
functioning properly
 Rarely causes signs and symptoms in its early stages
 As liver function deteriorates, the signs and symptoms appear, including
fatigue, nausea, unintended weight loss, jaundice, bleeding from the
gastrointestinal tract, intense itching, and swelling in the legs and abdomen
 Chronic alcoholism is the most common cause of cirrhosis
 Other causes:
 Chronic hepatitis B (HBV), C(HCV), and D virus (HDV) infection,
autoimmune hepatitis, inherited disorders (e.g., α1-antitrypsin deficiency,
Wilson disease, hemochromatosis, and galactosemia), nonalcoholic
steatohepatitis, blocked bile ducts, drugs, toxins, and infections

Tumors
 classified as primary or metastatic
 Primary: begins in the liver cells
 Metastatic cancer occurs when tumors from other parts of the body spread
(metastasize) to the liver (more common)
 Tumors of the liver may also be classified as benign or malignant
 Common benign tumors of liver include:
 Hepatocellular adenoma (a condition occurring almost exclusively in
females of child-bearing age)
 Hemangiomas (masses of blood vessels with no known etiology)
 Malignant tumors:
 hepatocellular carcinoma (HCC) (also known as hepatocarcinoma, and
hepatoma)- most common
 Bile duct carcinoma
 Approximately 85% of the new cases of this liver cancer occur in developing
countries, with the highest incidence of HCC reported in regions where HBV is
endemic such as Southeast Asia and sub-Saharan Africa
 Currently, orthotopic liver transplantation in people with HCC with underlying
cirrhosis who meet the Milan criteria (single tumor ≤5 cm in size or ≤3
Plaza, George Carr G. – Liver Function – Assignment

tumors each ≤3 cm in size, and no macrovascular invasion) is also

available for HCC

Reye’s syndrome
 A group of disorders caused by infectious, metabolic, toxic, or drug-induced
disease
 Found almost exclusively in children
 Often preceded by a viral syndrome such as varicella, gastroenteritis, or an
upper respiratory tract infection such as influenza
 Demonstrated a strong epidemiologic association between the ingestion of
aspirin during a viral syndrome
 Is an acute illness characterized by noninflammatory encephalopathy and fatty
degeneration of the liver
 The encephalopathy is characterized by a progression from
mild confusion (stage 1) through progressive loss of neurologic function
to loss of brain stem reflexes (stage 5)
 Degeneration of the liver is characterized by a mild
hyperbilirubinemia and threefold increases in ammonia and the
aminotransferases (aspartate aminotransferase [AST] and alanine
aminotransferase [ALT])
 Has a clinical presentation of profuse vomiting accompanied with varying
degrees of neurologic impairment such as fluctuating personality changes and
deterioration in consciousness
 Centers for Disease Control and Prevention (CDC) cautioned physicians and
parents to avoid salicylate use in children with a viral syndrome

Drug- and Alcohol- related disorders

 Accounting for one-third to one-half of all reported cases of acute liver failure
 Immune-mediated injury to the hepatocytes - most common mechanism of
drug toxicity
 induces an adverse immune response directed against the liver itself and
results in hepatic and/or cholestatic disease
 Ethanol - most important drug associated with hepatic toxicity
 causes very mild, transient, and unnoticed injury to the liver; however,
with heavier and prolonged consumption, it can lead to alcoholic
cirrhosis
 Approximately 90% of the alcohol absorbed from the stomach and small
intestines is transported to the liver for metabolism.
 Alcohol dehydrogenase and Acetaldehyde dehydrogenase
 convert alcohol to acetaldehyde and subsequently to acetate.
 can then be oxidized to water and carbon dioxide, or it may enter
the citric acid cycle
 Long-term excessive consumption of alcohol can result in a spectrum of liver
abnormalities that may range
 Alcoholic fatty liver with inflammation (steatohepatitis) --> scar tissue
formation, as in hepatic fibrosis --> hepatic cirrhosis (destruction of
normal liver structure)
Plaza, George Carr G. – Liver Function – Assignment

 Alcohol-induced liver injury may be categorized into three stages:

 Alcoholic fatty liver
 Mildest category
 Characterized by slight elevations in AST, ALT, and γ-
glutamyltransferase (GGT), and on biopsy, fatty infiltrates are noted
in the vacuoles of the liver
 Affect young to middle-aged people with a history of moderate
alcohol consumption
 Alcoholic hepatitis
 Fever, ascites, proximal muscle loss, and far more laboratory
evidence of liver damage such as moderately elevated AST, ALT,
GGT, and alkaline phosphatase (ALP) and elevations in total bilirubin
greater than 5 mg/dL
 Serum proteins, especially albumin, are decreased and the
international normalized ratio (INR, which is a ratio of coagulation
time in the patient compared with a normal coagulation time) is
elevated
 Alcoholic cirrhosis
 Dependent on the nature and severity of associated conditions such
as a gastrointestinal bleeding or ascites
 appears to be more common in males
 symptoms tend to be nonspecific and include weight loss, weakness,
hepatomegaly, splenomegaly, jaundice, ascites, fever, malnutrition,
and edema
 Laboratory abnormalities include increased liver function tests (AST,
ALT, GGT, ALP, and total bilirubin), decreased albumin, and
 a prolonged prothrombin time
 A liver biopsy is the only method by which a definitive diagnosis
may be made
 Acetaminohen - one of the most common drugs associated with serious
hepatic injury
 Others:tranquilizers, some antibiotics, antineoplastic agents, lipid-
lowering medication,and anti-inflammatory drugs

HEPATITIS
 injury to the liver characterized by the presence of inflammation in the liver
tissue
 Infectious causes for the inflammation of liver: viral, bacterial, and parasitic
infection
 Noninfectious causes: radiation, drugs, chemicals, and autoimmune diseases
and toxins.
 Viral infections account for the majority of hepatitis cases observed in the
clinical setting.
 Major hepatitis subtypes include HAV, HBV, HCV, HDV, and HEV

Nucleo Incubatio Primary Vaccin Chronic Serologic

tide n Period MOT e Infectio Diagnosis
Availab n Available
Plaza, George Carr G. – Liver Function – Assignment

ility
Hepatitis RNA 2-6 weeks Fecal-oral Yes NO YES
A
Hepatitis DNA 8-26 Parenteral; Yes Yes YES
B weeks sexual
Hepatitis RNA 2-15 Parenteral; No Yes YES
C weeks sexual
Hepatitis RNA - Parenteral; Yes Yes YES
D sexual
Hepatitis RNA 3-6 weeks Fecal-oral No ? YES
E

HEPATITIS A (HAV)
 Known as infectious hepatitis or short-incubation hepatitis
 The most common form of viral hepatitis
 Caused by a nonenveloped RNA virus of the Picornavirus family
 Most common reported source of infection in the household occurring via
contaminated or improperly handled food
 Fecal-oral route: Primary means of HAV transmission
 Symptoms are generally self-limited and resolve within 3 weeks
 Measured through the presence of serologic antibodies
 IgM antibodies to HAV (IgM antiHAV) are detectable at or prior to the
onset of clinical illness and decline in 3 to 6 months
 IgG antibodies to HAV (IgG anti-HAV) appear soon after IgM, persist
for years after infection, and confer lifelong immunity
 The presence of elevated titers of IgG anti-HAV in the absence of IgM
indicates a past infection
 Another reliable method to detect acute infection in patients is assaying for the
presence of viral antigen
 Antigen is no longer present soon after liver enzymes have reached their
peak levels
 Amplification of viral RNA by reverse transcription–polymerase chain reaction
(RT-PCR)
 More sensitive method of detecting HAV infection

HEPATITIS B (HBV)
 Known as serum hepatitis or long-incubation hepatitis
 Can cause both acute and chronic hepatitis
 The most ubiquitous of the hepatitis viruses
 Highest incidence among adults aged 25- 45 years
 Comparatively stable in the environment and remains viable for longer than 7
days on environmental surfaces at room temperature
 Detected in virtually all body fluids, including blood, feces, urine, saliva, semen,
tears, and breast milk
 The three major routes of transmission:
 Parenteral
 Perinatal
 Sexual
Plaza, George Carr G. – Liver Function – Assignment

Serologic Markers of HBV Infection

 HBV is a 42-nm DNA virus classified in the Hepadnaviridae family.
 Liver - primary site of HBV replication
 The core of the anitgen is synthesized in the nuclei of hepatocytes and then
passed into the cytoplasm of the liver cell, where it is surrounded by the protein
coat.
 Serologic Markers:
 Hepatitis B Surface Antigen
 Previously known as the Australia antigen and hepatitis associated
antigen,
 Antigen for which routine testing is performed on all donated units of
blood.
 A useful serologic marker in patients before the onset of clinical
symptoms because it is present during the prodrome of acute HBV
 HBsAg is not infectious; however, its presence in the serum may
indicate the presence of the hepatitis virus.
 Only serologic marker detected during the first 3 to 5 weeks after
infection in newly infected patients.
 The average time from exposure to detection of HBsAg is 30 days
(range 6 to 60 days).74-76
 The presence of anti-HBs antibody in patient indicates of past infection.
 Patients who have developed the antibody to the HBsAg are not
susceptible to future reinfection with HBV
 Hepatitis B Core Antigen
 Has not been demonstrated to be present in the plasma of hepatitis
victims or blood donors.
 Present only in the nuclei of hepatocytes during an acute infection with
HBV.
 The antibody to the core antigen, anti-HBc, usually develops earlier in
the course of infection than the antibody to the surface antigen
 The presence of this IgM antibody is specific for acute HBV infection. In
patients who have chronic HBV infection, the IgM anti-HBc antibody
titer can persist during chronic viral replication at low levels that
typically are not detectable by assays
 Persons with exacerbation of chronic infection can test positive for IgM
anti-HBc
 A viral DNA-dependent DNA polymerase that is closely associated with
the presence of the core antigen.
 This viral enzyme is required for viral replication
 Detectable in serum early in the course of viral hepatitis, during the
phase of active viral replication
 Hepatitis B e Antigen
 Closely associated with the core of the viral particle
 Detected in the serum of persons with acute or chronic HBV infection
 Presence of HBeAg in HBsAg carriers is an unfavorable prognostic sign
and predicts a severe course and chronic liver disease
 Detected in serum only when surface antigen is present
 No serological assays are available
Plaza, George Carr G. – Liver Function – Assignment

 No free HBcAg circulates in blood

Chronic Infection with HBV

 Approximately 90% of patients infected with HBV recover within 6 months
 The likelihood of developing chronic HBV infection is higher in individuals
infected perinatally (90%) and during childhood (20% to 30%)
 The immune system is thought to be less developed and unable to achieve
efficient viral clearance, than in adult immunocompetent subjects (<1%)
 Presence of HBsAg in chronically infected patients = indication that they
are infectious and at risk for developing complications, including cirrhosis
and HCC

HBV Treatment and Prevention

 HBV vaccination
 most effective measure to prevent HBV infection and therefore obviate its
consequences, including cirrhosis of the liver, liver cancer, liver failure, and
death.
 HBsAg is the antigen used for HBV vaccination
 Stimulate the production of hepatitis B surface antibody
 Advisory Committee on Immunization Practices (ACIP)
 recommended universal HBV vaccination for all unvaccinated adults at
risk for HBV infection and for all adults requesting protection from HBV
infection.
 The hepatitis B immune globulin (HBIG)
 provides passively acquired anti-HBs and temporary protection (i.e., 3 to 6
months) when administered in standard doses.
 is used as an adjunct to HBV vaccine for postexposure
immunoprophylaxis to prevent HBV infection

HEPATITIS C(HCV)
 caused by a virus with an RNA genome that is a member of the Flaviviridae
family
 Transmitted parenterally, primarily by blood transfusion of inappropriately
screened blood products
 Most infections become chronic and may lead to cirrhosis, end-stage liver
disease, HCC, and death

Laboratory Tests for Hepatitis C

 Hepatitis C antibody is usually not detected in the first few months of
infection but will almost always be present in the later stages
 Not protective against reinfection and sometimes disappears
 Currently, two laboratory tests are commonly used to diagnose HCV infection in
clinical practice:
 Anti-HCV detection by EIA (enzyme immunoassay) - most common
approach (1)
 If this test gives a positive result, the next step is to test for serum
HCV RNA by PCR.
Plaza, George Carr G. – Liver Function – Assignment

 The HCV antibody test is designed to detect antibodies generated in

response to HCV infection
 Cannot determine whether the patient is currently infected
with HCV or has recovered from HCV infection
 Patients (antiHCV positive but HCV RNA negative) are recommended
to retake the test for HCV RNA on a second occasion, 3 to 6
months after the first HCV RNA test.
 Quantitative nucleic acid PCR assays for serum HCV RNA (2)

Chronic HCV Infection

 Most patients with HCV infection progress to chronic infection
 Alcohol consumption concomitant with chronic HCV infection significantly
increases the risk of cirrhosis.
 Liver biopsies are performed periodically in these patients, with the degree of
inflammation and fibrosis correlating with the risk of cirrhosis
 Patients with chronic HCV infection are usually treated with pegylated interferon
and ribavirin.
 Therapeutic efficacy is monitored by using PCR to determine the
number of viral copies in serum.

HEPATITIS D(HDV)
 HDV is a unique subviral satellite virus infection.
 It is a small, defective RNA-containing virus that cannot replicate independently
but rather requires the HBsAg of HBV for replication
 Incapable of causing any illness in patients who do not have HBV infection
 HDV virions possess an outer envelope composed of HBsAg proteins and host
membrane lipids and an inner nucleocapsid consisting of viral RNA and
hepatitis delta antigen (HDAg)
 HBsAg-mediated binding to a cellular receptor helps HDV penetrate the
hepatocyte
 HDV infection can occur concurrently with HBV infection (coinfection) or in a
patient with established HBV infection (superinfection)
 The rate of chronicity following coinfection with HBV and HDV is equal to
that of HBV infection alone.
 HDV superinfection is likely to become chronic simply because HBV infection
is already chronic.
 Diagnosis: Detection of antibodies against HDAg and serum HDV RNA, as well
as HBV markers
 Clinical symptoms of HDV cannot be distinguished from those of other
hepatic viruses.
 Accurate diagnosis is made by a negative test for IgM anti-HBc and
confirmed by the detection of HDV markers.
 Interferon-α - currently the therapy used for treating chronic HDV
infection.

HEPATITIS E
 Nonenveloped RNA virus that is only 27 to 34 nm in diameter
Plaza, George Carr G. – Liver Function – Assignment

 The sole member of the genus Hepevirus in the family Hepevirida

 Incubation period: generally between 21 and 42 days prior to the onset of
symptoms
 May be detected in feces and bile by about 7 days after infection
 Can be transmitted by fecal-oral route
 Nonhuman mammals such as pigs, cows, and sheep are susceptible to infection
with HEV (zoonosis)
 Can be devastated to pregnants; however; normally, it is a mild infection
 Diagnosis is made by biochemical assessment of liver function
 Acute HEV is diagnosed when the presence of IgM anti-HEV is detected
 EIA and immunochromatography are most convenient for the detection of
IgM and/or IgG anti-HEV
 HEV should be suspected in outbreaks of waterborne hepatitis occurring in
developing countries
 No commercially available vaccine

OTHER FORMS OF HEPATITIS

1. Hepatitis F is an enteric agent that may be transmitted to primates.
2. The GB group of flavo-like viruses, GBV-A, GBV-B, and GBV-C, are also
associated with acute and chronic hepatitis.
3. Cytomegalovirus, Epstein-Barr virus, and probably several other agents can
also cause hepatitis

Reference:
Bishop, M. L., Fody, E. P., & Schoeff, L. E. (2018). Clinical chemistry: principles,
techniques, and correlations. 8th ed. Philadelphia: Wolters Kluwer Health/Hippincott
Williams & Wilkins.