EVALUATION OF LIVER FUNCTION

Henry’s Clinical Diagnosis and Management, 24th ED.

The liver is composed of three systems:

1. hepatocyte, concerned with metabolic reactions, macromolecular (especially protein) synthesis,
and degradation and metabolism of xenobiotics (e.g. Drugs)
2. biliary system, involved with metabolism of bilirubin & bile salts
3. reticuloendothelial system, concerned with the immune system & the production of heme &
globin metabolites (e.g. bilirubin).

KEY POINTS
 The function of each of these systems can be measured conveniently & virtually noninvasively by
determining the serum levels of specific analytes in the so-called liver function test profile.
 One of the most common causes of acute liver injury is viral hepatitis, mainly hepatitis A, B, &
C, all of which induce acute elevations of serum alanine & aspartate aminotransferases.
 Diagnosis of viral hepatitis can be made by screening for viral antigens, esp. In hepatitis B, & for
immunoglobulin M & G directed against specific viral antigens.
 Confirmation of the diagnosis as of a particular form of viral hepatitis is carried out using suitable
molecular diagnostic techniques such as real-time PCR using primers encoding specific viral
gene sequences.
 The diagnosis of specific liver diseases, including hepatitis, cirrhosis, chronic passive congestion,
acute biliary obstruction, space-occupying lesions, autoimmune diseases, & fulminant hepatic
failure can be made from specific patterns of serum liver function tests & from the presence of
specific antibodies in the serum.

¡ METABOLIC FUNCTIONS
ü BILIRUBIN METABOLISM
ü AMMONIA METABOLISM
ü LIPID METABOLISM
ü DRUG METABOLISM

¡ SYNTHETIC FUNCTIONS
ü PROTEIN SYNTHESIS
ü ALBUMIN
ü α1-ANTITRYPSIN
ü CERULOPLASMIN
ü CLOTTING FACTORS
Metabolic Functions - Bilirubin
Causes of Elevated Serum Levels of UNCONJUGATED BILIRUBIN
o Hemolysis
o Gilbert Syndrome: mutation in UGT1A1 gene
 -transport deficit in the sinusoidal membrane of the hepatocytes
o Crigler-Najjar Syndrome : multiple mutations in UGT1A1 gene
 Type I – more severe; associated with kernicterus
 Type II – less severe
Causes of Elevated Serum Levels of CONJUGATED BILIRUBIN
o Dubin-Johnson Syndrome
 defect in ATP-binding cassette (ABC) canalicular multi-specific organic anion
transporter (MRP2/cMOAT/ABCC2)
 associated with intense dark pigmentation of the liver
o Rotor Syndrome
 viral origin
 cytosolic inclusion bodies within hepatocytes
o Biliary Obstruction
 Cholelithiasis
 Inflammatory conditions – ascending cholangitis, gram-negative sepsis, hepatitis
 Others – septicemia, drugs, fasting
Laboratory Tests
CONVENTIONAL SPECTROPHOTOMETRY
diazotized sulfanillic acid
accelerants: caffeine or methanol
DRY SLIDE TECHNOLOGY
Differential spectrophotometry
*The sum of the direct and indirect bilirubin does not equal total bilirubin

Metabolic Functions - Ammonia

o Krebs-Henseleit (Urea) Cycle
 ammonia , urea
 critical enzymes uniquely contained in the liver
 elevated serum levels of ammonia indicate form of liver failure
o Laboratory Methods
 ENZYMATIC ASSAYS
-glutamate dehydrogenase
 DRY SLIDE METHOD
-alkaline buffer, bromphenol blue (indicator)
Metabolic Functions – Cholesterol & Other Lipids
o Severe liver injury:
 lipoprotein derangements result in a pattern that of the abnormally migrating beta
lipoprotein (typical of type III hyperlipoproteinemia)
 Increased TG, increased VLDL, increased phospholipids, decreased HDL
o Alcohol-induced liver injury
 PGA index
o PT (increased), GGT (increased), ApoAI proten (increased)
 increased HDL
o Cholestasis
 increased Cholesterol

Metabolic Functions – Bile Salts

o used in the diagnosis of cholestasis
o Primary bile salts: cholate & chenodeoxycholate
o Secondary bile salts: deoxycholate & ursodeoxycholate
o Cirrhosis:
-decreased ratio of (primary bile salts:secondary bile salts)
o Cholestasis:
-increased ratio of (primary bile salts:secondary bile salts)
o Laboratory method:
High-performance Liquid Chromatography (HPLC)

Metabolic Functions – Drug Metabolism

o microsomes of hepatocyte
o Cytochrome P450
o used to measure liver damage
o Laboratory methods:
 BREATH TESTS
-radio-labeled drug (13C)
-measurement of 13CO2
-2 categories:
Dependent on enzymatic activity of cytochrome P450
Dependent on rate of blood flow
-estimation of extent of liver damage

Synthetic Functions – Protein Synthesis

o synthesis of >90% of all proteins & 100% of albumin occurs in the liver
 o 2 vital measurements of liver function:
 Total protein
 Albumin
o Laboratory Method – Serum Protein Level:
 BIURET METHOD : Color complexes with copper
 DYE-BINDING METHOD: Coomassie blue, bromcresol green, bromcresol
purple
 SERUM PROTEIN ELECTROPHORESIS & QUANTITATIVE Igs

o ALBUMIN

low serum levels due to liver disease are almost always caused by massiv
destruction of liver tissue
o ALPHA-1-ANTITRYPSIN (AAT)
o CERULOPLASMIN
 Wilson disease

Synthetic Functions – Clotting Factors

o Disseminated Intravascular Coagulopathy (DIC)

 most common coagulopathy in liver failure
 Laboratory tests:
D-DIMER
FIBRIN SPLIT PRODUCTS
o Liver-associated Coagulation Abnormalities:
 Laboratory tests:
-PT
-PT INR
-DES-GAMMA-CARBOXY PT - hepatocellular carcinoma

CAVEATS ON USING PT & INR IN LIVER FUNCTION

 Any coagulation disorder will give rise to abnormal PT &/or PTT, independent of liver function
 In cholestasis, absorption of fat-soluble vitamin K from the gut may be impaired
 INR is based on PT values for patients treated with Coumadin
 PT is used to compute for Model for End-stage Liver Disease (MELD) score

Tests for Liver Injury

 o AMINOTRANSFERASES
• Aspartate Aminotransferase (AST) and Alanine Aminotransferase (ALT)
• BOTH Require pyridoxal phosphate (vitamin B6) as a cofactor
• AST : cardiac muscle, liver, skeletal muscle, kidney, brain, lung and pancreas
• ALT : confined primarily to the liver, kidney and muscle
• AST/ALT quotient, also called The DeRitis ratio
• Reference range 0.5 – 0.7

Acute hepatitis AST > ALT

>24-48 hours AST < ALT
Chronic hepatitis AST < ALT
Cirrhosis AST > ALT
ESLD ↓AST & ↓ALT

• Overall, ALT is more specific for detecting liver disease in nonalcoholic, asymptomatic
patients

Other Markers for Hepatocytic Injury

o LACTATE DEHYDROGENASE (LD)
 Widely distributed and nonspecific, but commonly elevated in liver injury
  Elevated in Hemolysis, Megaloblastic Anemia, Disorders of muscle, liver, kidney and lung
 Elevated in neoplastic states including leukemia, lymphoma, germ cell tumors and carcinomas
 5 isoenzymes ( LD1, LD2, LD3, LD4, LD5 )
-LD 4 and LD 5 elevated in liver injury

Enzymes reflecting Canalicular Injury

o ALKALINE PHOSPHATASE
 marker of biliary dysfunction
 Concentrated in bone, liver, intestine and placenta
 Usually assesses in conjunction with other tests (GGT and 5 nucleotidase)
 If these are within normal limits  excess alkpaline phosphatase is probably of bone origin
 Nonpathologic conditions that affect Alk Phos: normal growth in children and pregnancy,
medications (OCPs)
 Compared to other liver Function test, most sensitive marker for hepatic metastases

o GAMMA-GLUTAMYLTRANSFERASE
 To corroborate an elevated Alkaline Phosphatase, or as a standalone test
 Highly sensitive indicator if hepatobiliary injury
 Elevated in chemical exposures like Warfarin, barbiturates, dilantin, valproate, methotrexate and
alcohol
 Elevated 2 – 3x in heavy drinkers

o 5’-NUCLEOTIDASE
 Main source is biliary epithelium
 Highest in cholestatic conditions

Other Enzymes
o ALPHA FETOPROTEIN
 elevated in neural tube defects
 marker for hepatocellular carcinoma
 levels >400 ng/dL  high probability of HCC
 Good prognostic tool
 Serum AFP levels dependent on the extent & degree of differentiation of the tumor, & age of
patient
 marker for germ cell tumors, especially yolk sac tumors

Autoimmune Markers
o ANTIMITOCHONDRIAL ANTIBODY (AMA)
 marker for primary biliary cirrhosis (PBC)
 Laboratory test:
 Antibody detection by IF, ELISA
 AMA with anti-M2 specificity is 100% specific for PBC
o ANTI-NEUTROPHIL CYTOPLASMIC ANTIBODY (ANCA)
 marker for primary sclerosing cholangitis (PSC): p-ANCA
 PSC: p-ANCA, Anti-nuclear antibodies (ANA), Anti-smooth muscle antibodies
(ASMA)

Serum Markers for Autoimmune Hepatitis

TESTING FOR VIRAL-INDUCED HEPATITIS

o HEPATITIS A VIRUS
• Picornavirus family of RNA viruses
• Transmission: Feco-oral route
• Incubation period: 15 to 50 days (30 days)
• self-limiting

Typical Time course of Hepatitis A virus

o HEPATITIS B VIRUS
• Hepadnavirus family
• Transmission:
• primarily by body fluids, especially serum
 • spread effectively by sexual and vertical transmission
• Incubation period: 4-12 weeks
• In most individuals, HBV hepatitis is self-limited

Typical Time course of Hepatitis B virus

Patterns for Hepatitis B Markers

 o HEPATITIS C VIRUS
• Flavivirus group (RNA virus)
• Transmission:
• transmitted via blood transfusions and transplantation (
• 60% in injection drug users
• Accidental needle punctures in health care workers
• Dialysis procedures in patients
• Incubation period: 4-12 weeks
• In most individuals, HBV hepatitis is self-limited

Patterns For Hepatitis C Markers

SUMMARIZED PATTERN OF LIVER FUNCTION TESTS IN DIFFERENT

CONDITIONS