Notes - Chemical Pathology – Liver Function Test

Routine liver function test – overview

- Hepatocyte damage: AST, ALT
- Biliary damage: ALP, GGT
- Synthetic function: Albumin, clotting factors (prothrombin time), globulin, total
protein
- Excretory function: Total bilirubin, unconjugated, conjugated bilirubin

1. Albumin and other proteins

Total Protein = Albumin + Globulins (Ig, complements, fibrinogen, a1-antrypsin etc)
 A:G > 1 normal
 A:G LESS than 1: when Albumin is low = reflects CIRRHOSIS OR CHRONIC LIVER
PROBLEM
- These proteins reflect: nutritional status, immune status, kidney, liver function

- Albumin – exclusively liver made, 3 weeks half life, indicates CHRONICITY

> most important protein in maintaining osmotic pull (retain fluid in blood)
Ie cirrhosis: no albumin = water out = ascites
 Decreased in:
Liver failure (reduced made), malnutrition, increased loss (nephrotic syndrome,
burns), inflammation, hypercatabolic state (sepsis, trauma)

- Coagulation proteins – clotting factor

Factor VII: 6-8 hours half-life, indicates ACUTE liver problem
Factor I (Fibrinogen)
 Measure ment of prothrombin time can assess liver synthetic function
- Prolonged: hepatocellular disease, Vitamin K deficiency (needed for clotting factor
activation)

2. Bilirubin and Jaundice

Bilirubin metabolism – Physiology
- Normal RBC turn over: Haemoglobin released
- Hb  Haem within reticuloendothelial system (Mac)
- 10% reabsorbed via enterohepatic circulation to liver,
cycle begins again
- Majority excreted in biliary system  stool
- Urobilin is oxidised form of urobilinogen = straw
colour urine

Conjugated bilirubin: with glucuronic acid in Hc, soluble

Unconjugated bilirubin: insoluble, bound to ALBUMIN
d-bilirubin: Covalently bound to albumin, not routine
measure
 bilirubin is the reason of yellowing of the skin
Jaundice
- Yellowing of the skin and sclera of eyes
Bilirubin profiles
Prehepatic: unconjugated bilirubinaemia. increased haemolysis
 Increased haemolysis: autoimmune, infection etc
NB: neonates also has unconjugated form: physiological jauncice, breast milk jaundice,
congenital hypoyhyroidism

Hepatic: Conjugated bilirubinaemia/ unconjugated

 Reduced conjugation capacity (Unconjugated): defects in UDP-GT enzymes
(Gilbert’s/ Crigler -Najjar)
 Hepatocyte injuries (Conjugated): hepatitis, cirrhosis, drugs
 Bile duct obstruction (Conjugated):
conjugated products cant get into gut to be excreted, backed up into blood
- PBC, PSC, Biliary atresia, inborn error of metabolism, a- trypsin definciency

Post hepatic cause: conjugated bilirubinaemia

Urine will ONLY have conjugated bilirubin as this unconjugated in INSOLUBLE

 Urine dipstick test: excreted via urinary system if levels are high in blood tea-coloured
urine
 False negative: aged samples, vitamin c, rifampicin
 False positive: phenothiazines

Urobilinogen
- Formed when gut microbiome converts conjugated bilirubin  urobilinogen
- Urobilinogen  stercobilin by bacteria in gut
- Urobilinogen  excreted by stool or to kidneys, excreted OR oxidised into urobilin,
excreted
- Stercobilin, urobilin
- Urine urobilinogen: sensitive, but non-specific for liver damage
- Increased in: early hepatitis, mild liver cell damage, mild toxic hepatic damage

- Biliary tract obstruction: Facts

 conjugated can’t get into gut to be  urobilinogen/ stercobilin
 conjugated backed up into blood, into urine
= URINE UNCONJUGATED, NO urobilin/urobilinogen (tea coloured urine)
= Clay-coloured stool

3. Liver enzymes – AST ALT GGT ALP

- Intracellular enzymes released into blood due to damaged membrane integrity
- Hepatocellular injuries: 10-100X increase
- Cholestasis: 10X or LESS increase
- Most significant increase: viral hepatitis, ischaemic/toxic injuries
- Least significant increase: cirrhosis, chronic hepatitis
 a. AST ALT – Parenchymal enzymes
AST: Heart, Liver, Kidneys, Pancreas, Spleen
 Isoforms: cytoplasmic, mitochondrial

ALT: liver, kidney predominantly = more specific for liver function

 Cytoplasmic only

b. ALP GGT – Ductal enzymes

ALP: bone, liver, intestines, placenta (pregnant women benign increase)
Liver: sinusoidal surface, microvilli of bile canaliculi and bile ducts
- Marker for cholestasis!
- Hepatocellular damage: slight increase or normal levels

Clinical states leading to raised ALP

- Pregnant
- Bone tumour/ metastasis
- Children: due to active bone growth
 Important to establish cellular source of ALP: heat stability test of isoforms
 Liver: more resistant to heat
 Bone: less resistant to heat
Other tests: electrophoresis, immuno-assay for bone specific ALP ($$)

Space occupying lesion in liver: HCC, abccess, metastasis

Outcome: partial obstruction of biliary tract = ISOLATED increase in ALP (GGT)
- Other liver enzyme not increased as hepatocyte function isn’t affected per se

c. GGT
- Present in bile canaliculi, more specific than ALP
- ALP + GGT elevation = sure its cholestatic disease
- Induced by: alcohol, drugs