Clinical Chemistry 2 Laboratory
o Functional units
LIVER
Functionally complex organ, play a biochemical role in
metabolism, digestion, detoxification, and elimination of
different substances. Also involved in excretory synthetic Microscopic anatomy of liver
and metabolic function which are all essential in life since
• Cell types
these are processes that the body needs every day in
order to function well. It can regenerate destroyed cell
but if it repeatedly damage, it will lead to irreversible
changes.
The functions of the liver
1. Excretion/secretion
Beneath and attached to the diaphragm protected by the
lower ribcage. Held in place by ligamentous attachment.
Right lobe is six times larger than the left lobe. Lobes are
divided by the falciform ligament. No known difference in
its function despite of having two lobes.
Anatomy of the liver
• Largest internal organ
• Weighs 1.2 – 1.5 kg
• Vascular system (source of blood supply)
Hepatic artery (supplies 25%
oxygen rich blood from
the heart to the liver)
Portal vein (supplies 75%
nutrient rich blood from
the digestive tract)
Blood flows through the sinusoids. Blood flows out of the
liver from the central canal. Approximately 1500 mL of
passes through the liver per minute.
Flow of excretory products
• Bile canaliculi form intrahepatic ducts, where
excretory products of the cell drain
• intrahepatic ducts → right and left hepatic ducts →
common hepatic duct → common bile duct →
duodenum.
Microstructure of the liver
• Lobules
o Six sided with central vein and portal triads
(composed of hepatic artery, portal vein and bile
duct)
o Hepatocytes
➢ 70% of volume of liver
➢ Regenerative (because of hepatocyte)
➢ Perform major functions of liver
o Kupffer cells (stellate macrophages)
➢ Macrophages acting as phagocytes
o Bile
➢ Water, electrolytes, phospholipids, bile salts
or acids, bile pigments, cholesterol, heme
waste products, and other substances from
blood
➢ 3L produced per day
➢ 1L excreted per day
➢ Bile acids needed for fat absorption
➢ Mechanism to remove cholesterol and waste
➢ Bilirubin is the principal pigment in bile
o Bilirubin
➢ The major heme waste product
➢ The principal pigment in bile
➢ Highly insoluble in water
➢ Hemoglobin = heme and globin + iron
2. Storage
3. Metabolism of CHO, CHONS, and lipids
o CHO metabolism
➢ Glycolysis (glucose being converted to
pyruvate)
➢ Glycogenesis (glycogen synthesis. Glucose
molecules are added to glycogen chains for
storage)
➢ Glycogenolysis (breakdown of glycogen)
➢ Gluconeogenesis (carbohydrate metabolism)
o CHON metabolism
➢ Synthesis of albumin, alpha and beta
globulins
➢ Coagulation proteins (except)
o Fat metabolism
➢ Synthesis of bile salts and lipids of acetyl-CoA
➢ Metabolism of lipids by LPL
4. Detoxification
o Allow the substances to reach the circulation:
“first pass” (all substances absorbed in the
digestive system must first pass in the liver)
o Excretion of steroid hormones, drugs, and
foreign compounds
Clinical Chemistry 2 Laboratory

o Usually occurs in the microsomes of the liver via
cytochrome P-450 isoenzymes (Kupffer cells
perform phagocytosis through oxidation,
hydrolysis, carboxylation, methylation, etc. to
help the liver to perform in detoxification)
5. Bilirubin synthesis
Liver function alterations during diseases
1. Jaundice (Icterus)
o Yellow discoloration of skin, eyes, and mucous
membranes (>3 mg/dL) (due to increased
bilirubin level)
o NV = 0.5 – 1.0 mg/dL
o Prehepatic
➢ Excessive destruction of RBC
➢ ↑total bilirubin (↑B1, normal B2)
➢ Acute and chronic hemolytic anemia
➢ HDN
➢ HTR
➢ Malaria
o Hepatic (intrinsic liver defect)
Gilbert • Unconjugated
syndrome hyperbilirubinemia due
(transport to defective conjugation
deficit) (most system
common) • Reduced expression of
UGT1A1 (UGT1A1 is
important in the
production of UD-PGT)
• ↑total bilirubin (↑B1,
normal B2)
Crigler-Najjar • Molecular defect of
(conjugation gene
deficit) (rare but • Type 1 – absence of
severe UDP-GT (uridine
syndrome) diphosphoglucose
glucoronyl transferase)
• Type 2 – deficiency of
UDP-GT
• ↑TB (↑B1↓B2
Dubin-Johnson • Deficiency of
(excretion MDR2/cMOAT (multi
deficit) drug
resistance/multispecific
organic anionic
transporter protein)
• ↑TB(normal B1, ↑B2)
• Bilirubinuria (bilirubin is
detected in the urine)
• Dark stained granules
• Presence of delta
bilirubin
• Uptake and conjugation
of bilirubin is okay but
the removal of
conjugated bilirubin and
excretion to the bile is
defective
Rotor syndrome • Deficiency of ligandin
• ↑TB (normal B1 ↑B2)
• No dark stained granules
Neonatal • Deficiency in the
physiologic glucoronyl transferase
syndrome • ↑TB (↑B1, normal B2)
• Leads to kernicterus
(unconjugated bilirubin
reaches 20mg/dL)
• Treated with
phototherapy
o Post hepatic
➢ Biliary obstructive disease
➢ Physical obstructions which prevent flow of
B2 into bile canal (bile not brought to the
intestine may produce gray colored stool)
➢ Gall stones
➢ Tumors
➢ ↑TB (normal B1, ↑B2) bilirubinuria
2. Cirrhosis
o Scar tissue replaces liver tissue resulting to
blockage of blood flow through the liver
o Irreversible
o Related to chronic alcoholism and chronic
hepatitis C
3. Tumors
o Primary or metastatic
Benign • Hepatocellular
adenoma (female)
• Hemangioma (blood
vessels)
Malignant • Hepatocellular
carcinoma
• Hepatocarcinoma and
hepatoma
• Predisposes from
cirrhosis and HBV/HCV
4. Reye syndrome
o Disorders preceded by infectious (viral) or drug
(aspirin) related disease in children
o Noninflammatory encephalopathy and fatty
liver degeneration
o Profuse vomiting, varying degrees of neurologic
impairment, and deterioration of consciousness
o Increased level of ammonia, AST and ALT are
three folds high
Clinical Chemistry 2 Laboratory

5. Drug and alcohol related disorders o Positive reaction: red

Alcohol related disorder • Clinical significance:
Alcoholic fatty liver • Inc. AST, ALT, and 1. Hemolytic disease
GGT 2. Hepatic disease
• Fatty infiltrates in 3. Biliary obstruction
vacuoles of liver
Liver markers: enzymes
Alcoholic hepatitis • Increased (2x) AST,
ALT, GGT, and ALP • AST
• Bilirubin 30 mg/dL, • ALT (specific to liver disease)
↓albumin ↑PT • LDH (normal in cirrhosis and obstructive jaundice)
Alcoholic cirrhosis • Increased (3x) AST, • ALP (associated with obstructive jaundice and
ALT, GGT, and ALP hemolytic jaundice)
• ↑bilirubin, • 5’NT (nucleotidase) (not affected by bone diseases.
↓albumin, ↑PT Has direct proportional relationship with ALT)
Drug related disorder • GGT
o Acetaminophen – hepatic necrosis
o Tranquilizers
Test for the synthetic function of liver
o Antineoplastic agents
o Lipid-lowering medication
o Anti-inflammatory drugs

Excretory function test

Direct Van den Bergh Indirect Van den Bergh

B2 + Diazo reagent → B1 + accelerator + Diazo
azobilirubin reagent → azobilirubin

Specimen collection and transport • Hepatic damage

o Cirrhosis β-y bridging
• Serum specimen
o Hepatits ↑y-globulins
• Hemolysis – false ↓
o ↓TP,↓Alb,↑Glob
• Lipemia – false ↑
• Immunoglobulin
• Photosensitive - ↓ by 30-50% per hour o Primary biliary cirrhosis (IgM)
• 2 days at RT, 1 week at 4C, indefinite at -20C o Chronic active hepatitis (IgG and IgM)
Methods of bilirubin analysis o Alcoholic cirrhosis (immunoglobulin A)
• Clotting factors
Malloy-Evelyn Jendrassik-Grof o Prothrombin time (PT)
(tested at 540 (tested at 600 o ↑ in liver disease
nm) nm) o Disruption of bile flow resulting in inadequate
(advantages: absorption of vitamin K in intestine (vitamin k
not affected by dependent factors: 2, 7, 9, 10)
pH changes,
insensitive to Test for detoxification
high protein • Test the ability of the liver to convert ammonia to
and not urea
affected by
• By product of amino acid deamination
hemoglobin)
(plasma/arterial blood as sample put into heparin
Accelerator - Ascorbic acid on ice)
Stopper None - • Hepatic failure and hepatic coma
pH 1.2 10.6
• Reye syndrome
End color Pink to purple Blue
• Inherited deficiencies of urea cycle
**Total bilirubin = indirect bilirubin + direct bilirubin**
• Test: GLDH – decrease in absorbance at 340 nm
Urobilinogen (colorless end product of bilirubin
metabolism)

• Ehrlich test
o Reagent: para dimethyl amino
benzaldehyde