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Clinical chemistry 2:
the liver
In this second article of the clinical chemistry series, we
look at the hepatic measurands commonly found on a
feline blood panel, including assays that assess hepatic
injury, cholestasis and liver function.

Introduction to enzymatic assays Matthew Garland

Several of the measurements discussed in this
article fall into the category of enzymatic
assays. Broadly speaking, each organ or cell
type contains different enzymes, some of
which are specific to a certain cell or tissue
type, which can be diagnostically useful.
Increased enzyme activity occurs when
increased amounts of certain enzymes are
present in the bloodstream either due to
leakage from damaged cells (inflammation,
necrosis, etc) or due to increased production.
Detection of this increased activity can then
suggest damage or stimulation to the cells
that produce these enzymes.
These measurements are made by measuring
the rate at which a substrate for the enzyme
of interest is converted to a product or the
rate at which the substrate disappears after
being mixed with a set amount of the
patient’s serum.
Things to consider when interpreting these
assays are the biologic half-life of the enzyme
of interest once it is in the bloodstream, the
tissue specificity of some enzymes and
substrate exhaustion on patient samples
with very high levels of enzyme activity.
Hepatic measurands
Most of the tests available for looking at liver
disease fall into three main categories:
enzymatic assays that test for hepatocyte
injury; enzymatic assays that detect
BSc RSciTech SAC DIP Cert Nat Sci Vn MRSB
Matthew Garland is a veterinary nurse and
registered science technician with a degree
in chemistry and molecular biology and over
20 years’ experience in the veterinary field.
He is currently a deputy director and
veterinary laboratory manager and teaches
student veterinary nurses key laboratory
skills. Matthew has contributed to several
published research projects, has had several
articles on veterinary haematology and
clinical biochemistry published and delivers
regular CPD. Being passionate about team
development and the development of others,
Matthew sits on the registers assessors
board of the Royal Society of Biology (RSB)
and is also a judge for the RSB Apprentice
of the Year award.
This article is the second in a
three-part series. The previous
article can be found in the July
issue and looked at where in the
body the measurands come from
and what the numbers mean. In
the third and final part of this
clinical chemistry series, we look
at the metabolic analytes found
in the feline blood profile.
cholestasis; and assays that test liver
function.1 Hepatocyte injury and
cholestasis can be caused by a
number of factors including metabolic

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diseases (eg, hyperthyroidism),
hypoxia, neoplasia, trauma and bile
duct obstruction, or can be
secondary to certain conditions
such as pancreatitis.1–3
Hepatocyte injury
This is detected by measuring
the serum activity of enzymes
that have leaked directly from
the hepatocytes.
Alanine aminotransferase
Alanine aminotransferase (ALT) is
found in the highest concentration
in the cytoplasm of hepatocytes in
feline patients.1–3 Though not only
found in hepatocytes (it can also
be found in muscle tissue) it is
considered to be the most liver-
specific test for hepatocyte injury.
In cases where muscle trauma is
observed, the ALT elevation should
be evaluated alongside creatine
kinase (see part !) to see if it is liver
or muscle-derived.2
Potential causes of ALT elevations:
• hypoxia;
• trauma;
• hepatocyte lipid accumulation;
• inflammation;
• neoplasia; and
• metabolic disorders.
Cholestasis
Impaired bile flow or cholestasis can
be detected by measuring alkaline
phosphatase (ALP, ALKP) and
gamma (γ)-glutamyltransferase
(GGT).3 Cholestasis expedites the
production of both ALP and GGT
and these measurands are
commonly found in feline
biochemistry profiles.
Alkaline phosphatase
Alkaline phosphatase (ALP) is an
enzyme that is found attached to
cell membranes and is synthesised
by many body tissues such as the
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liver, bone, intestines, pancreas and
kidneys.1,2 There are different
isoenzymes of ALP but further
discussion is beyond the scope of
this article. Most of the ALP that we
commonly measure originates from
the liver as other types of ALP have
a very short half-life in cats, for
example, intestinal ALP has a half-
life of 2 mins.3
Potential causes of ALP elevations:
• cholestasis;
• hepatobiliary disease;
• osteoblastic activity – bone
formation;
• young kittens; and
• neoplasia.
GGT
GGT is also an enzyme that is
found attached to cell membranes.1,2
It is synthesised by most body
tissues but is found in highest
concentrations in the kidneys and
pancreas. However, the vast majority
of GGT activity in feline patients
originates in the liver. In cats, GGT
is considered more sensitive for the
detection of liver disease compared
with ALP, but is less specific.3
Hepatic lipidosis deserves a special
mention as it is a serious condition
in the feline patient (Figure 1). Cats
with hepatic lipidosis will usually
have a greater elevation in serum
ALP and serum GGT. However, GGT
may sometimes still be within the
reference range of the analyser.
Potential causes of ALP elevations:
• cholestasis;
• hepatobiliary disease; and
• hepatic lipidosis.
Liver function tests
Liver function tests commonly
measure the serum levels of
substances filtered from the blood
by the liver and then metabolised
and/or excreted via the biliary
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Figure 1: Hepatic lipidosis is a serious condition in
feline patients and cats with this condition will usually
have a greater elevation in serum alkaline phosphatase
and serum gamma-glutamyltransferase
system. These measurands can also
be elevated in conditions that are
not hepatic related, but if elevations
are seen alongside those measurands
mentioned above, then they are
considered hepatic related.
Bilirubin
Bilirubin is primarily formed in
the process of red blood cell
destruction.1–3 Red cells are destroyed
at a constant rate due to cell ageing,
but this process can be accelerated
in conditions such as autoimmune
haemolytic anaemia or leptospirosis.
Bilirubin is formed as a product of
haemoglobin degradation and
contains proteins such as myoglobin.2
At the end of the haemoglobin
degradation cycle, recycled
protoporphyrin is delivered to the
hepatocytes via albumin in the form
of bilirubin. The hepatocytes can
become saturated in cases of
haemolytic anaemia, which can lead
to increased serum bilirubin levels.2,3
There are three main causes
of increased serum bilirubin
concentrations (hyperbilirubinaemia):
• increased production owing
to increased red cell destruction;
• decreased uptake by hepatocytes;
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and
• decreased bilirubin excretion –
cholestasis.
Bile acids
The bile acid stimulation test is the
most common test utilised in practice
for determining hepatic function. Bile
acids are synthesised in hepatocytes
from cholesterol and are made up
of cholic acid and chenodeoxycholic
acid in most animals.3 Bile acids are
stored and concentrated in the
gallbladder in cats. When they eat,
the gallbladder contracts and the bile
acids are excreted into the small
intestines.2,3 Bile acids’ primary
function is to promote the digestion
and absorption of fat as well as
fat-soluble vitamins.
Most bile acids are then reabsorbed
from the ileum into portal circulation
where they are usually removed
by the liver. Once back inside the
hepatocytes, they are secreted into
the biliary system and the process
starts again. This process can happen
several times after a meal, and in
healthy cats, there is only a nominal
elevation in post-prandial bile acids.
Three main pathological processes
cause increased serum bile acids:
• Decrease in functional
hepatocytes: this can be caused
by hepatitis, for example, which
leads to hepatocyte damage,
reducing their ability to absorb
bile acids.
• Abnormal portal circulation:
the most common cause of
poor portal circulation is a
portosystemic shunt. In this
situation, the blood is shunted
away from the liver cells removing
the ability to absorb the bile acids
from the blood.
• Decreased excretion: this can be
the result of posthepatic cholestasis
caused by a gallbladder obstruction
or hepatic inflammation.
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Possible causes bile acid
elevations:
• portosystemic shunts;
• cholestasis;
• necrosis;
• hepatic lipidosis;
• neoplasia; and
• hepatitis.

In cats, fasting bile acid levels

are not consistently elevated with
the conditions listed above so
measuring a pre- and post-prandial
level should always be a
consideration.2

It is worth noting that lipaemia can

cause false increases in bile acids
and haemolysis can cause false
decreases. This is assay dependent
but worth bearing in mind.

The liver is a complex organ and

further reading is recommended
when interpreting liver parameters,
as a diagnosis can depend on the
magnitude of the changes seen in
the blood profile.

References
1 Villers E and Ristic J. BSAVA manual of canine
and feline clinical pathology. 3rd ed.
Gloucester: BSAVA, 2016.
2 Stockham SL and Scott MA. Fundamentals of
veterinary clinical pathology. 2nd ed. Hoboken,
NJ: Wiley-Blackwell, 2013
3 Latimer KS. Duncan and Prasse’s veterinary
laboratory medicine. 5th ed. Hoboken, NJ:
Wiley-Blackwell, 2011.

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