CLIN CHEM | LIVER FUNCTION TRISHA LORAINNE R.

VILLOCENO

INTRODUCTION LIVER: BIOCHEMICAL

 LIVER is one of the complex organs in the
body
 It is responsible for performing vital tasks
that affects and encompasses all body
systems
 It is capable of regenerating cells
 May undergo irreversible changes is
repeatedly damage and lead to failure of liver
function
LIVER: BASIC ANATOMY
 Weight: 1.2 to 1.5 kg (vary on each person)
 Divided unequally into 2 lobes by a falciform
ligament
Falciform
ligament
FUNCTIONS
A. EXCRETION/SECRETION
o Liver is capable of processing and
excretion of endogenous and exogenous
substances into the bile (become stool) or
urine
o Bile is made up of bile acids or salts, bile
pigments, cholesterol and other
substances extracted from the blood
o Body produces approx. 3 L of bile per day
and excreted 1 L of what is produced
o Bilirubin – Principal pigment present in bile;
derived from the breakdown of RBCs
o Approx. 200 to 300 mg of bilirubin is
produced per day
o 2 types of Bilirubin: Unconjugated and
Conjugated
o Healthy adult has very low levels of
bilirubin: 0.2 to 1.0 mg/dL
o If there are diseases/liver is damaged,
bilirubin level increases

 Right lobe is approx, 6x larger than the left

lobe
 Blood supply is from:
 Hepatic artery – oxygen-rich, from the
heart (25%)
 Portal vein – nutrient-rich, from the
intestine (75%)
 Lobule: Functional unit of liver (responsible
for excretory and metabolism function of
liver)
 2 major cell types:
 Hepatocytes – comprises majority of liver
cells; responsible for performing major
functions of the liver
 Kupffer cells – macrophages of the liver
CLIN CHEM | LIVER FUNCTION TRISHA LORAINNE R. VILLOCENO

Bilirubin Metabolism/Urobilinogen Excretion  Indirect  Cholebilirubin

 RBC = breakdown, release Hemoglobin (reacting)  Fast-reacting
 Hemoglobin = heme + globin
 Heme = composed of Iron and it will be salvaged,
bilirubin  Severely
stored at liver and bone marrow to make more RBC  Hemobilirubin increased in Post
(Globin = protein, go to liver and store in amino acid  Slow-reacting hepatic jaundic
pool)  Severely
 Heme w/o iron is converted to unconjugated
increased in Pre-
bilirubin using 2 enzymes:
 Heme oxidase – convert heme to biliverdin hepatic jaundice
 Biliverdin reductase – convert biliverdin to
bilirubin B. METABOLISM/SYNTHESIS
 Unconjugated bilirubin = water-insoluble, it should
o Liver is responsible for metabolizing
be converted to the liver to become water soluble.
It needs a carrier protein which is the albumin.
biological compounds – Carbs, Lipids,
Unconjugated bilirubin bound to albumin reach the Proteins
hepatocyte (liver cell), and ligandin (protein within o When Carbs are ingested and absorbed,
the hepatocyte) takes up unconjugated bilirubin the liver can:
then delivers it to endoplasmic reticulum of liver
Use glucose from carbs for its own
cell
 At endoplasmic reticulum, UDP-glucuronyl cellular energy
transferase enzyme conjugates/converts Circulate glucose for use at the
unconjugated bilirubin to conjugated bilirubin. It peripheral tissues
conjugates unconjugated bilirubin by attaching 2
Store glucose as glycogen within the
glucuronic acid molecules to propionic acid molecule
of unconjugated bilirubin.
liver or within other tissues
 After conjugation, it will become conjugated (Glycogenesis)
bilirubin aka Bilirubin Diglucuronide and it is now Degrade stored glycogen depending on
water soluble. It will go to the intestine then it will body’s needs (Glycogenolysis)
be converted to urobilinogen (colorless) by GI
When needed, the liver can create
bacteria
 Urobilinogen is oxidized as urobilin or stercobilin glucose from non-sugar substances
(giving color to stool) and 80% is excreted to feces, such as pyruvate, lactate, and amino
50-250 mg excreted/day acids (Gluconeogenesis)
 20% of urobilinogen is absorbed and
o Capable of metabolizing lipids and
recirculated in the liver and reexcreted in the
feces (Extrahepatic Circulation)
lipoproteins and gathering free fatty acids
 Small portion of urobilinogen enters o Majority of cholesterol in the body is
circulation and excreted in the urine (Systemic produced by liver
Circulation) o All proteins are synthesized by liver
 1-4 mg urobilinogen excreted in urine/day
except Immunoglobulins (by B cells) and
Adult Hemoglobin (by Red cells)
Unconjugated vs. Conjugated Bilirubin
o Albumin – one of the most important
Unconjugated Conjugated protein synthesized by liver
Bilirubin Bilirubin o Extensive damage in the liver causes it to
 Bilirubin 1 (B1)  Bilirubin 2 (B2) lose its ability to metabolize and
 Water insoluble  Water soluble synthesize biological compounds
 Non-polar  Polar bilirubin
bilirubin  Direct (reacting)
bilirubin
CLIN CHEM | LIVER FUNCTION
C. DETOXIFICATION & DRUG METABOLISM
o Liver is capable of detoxifying harmful
substances such as toxins and prevent it
from reaching the systemic circulation –
substances absorbed by the GI tract pass
through the liver (First Pass)
o Allows essential substances to reach
circulation, while toxic and harmful
substances are prevented from entering
the circulation
o Two mechanisms for detoxification:
Inactivation through binding
Chemical modification
o Responsible for metabolizing drugs
D. STORAGE
o Storage site for all fat-soluble and water-
soluble vitamins
o Storage site for glycogen
o Amino acid pool – store amino acids
ALTERATIONS IN LIVER
FUNCTION DURING DISEASES
A. JAUNDICE
o Yellow discoloration of skin, eyes and
mucous membranes
o Overt jaundice (not observed): 1.0-1.5
mg/dL bilirubin levels
o Noticeable jaundice: 3.0-5.0 mg/dL
bilirubin levels
o ICTERUS: serum or plasma sample with
yellow discoloration due to bilirubin
o Prehepatic, Hepatic and Post-hepatic; only
the hepatic jaundice is caused by damage
of liver function
Prehepatic Jaundice
 Occurs when the problem causing happens
prior to liver metabolism
 Increased unconjugated bilirubin in the
blood
 Usually happens in hemolytic anemias
TRISHA LORAINNE R. VILLOCENO
 Also be referred to as Unconjugated
Hyperbilirubinemia
 Liver function is usually normal
Hepatic Jaundice
 Occurs when primary problem causing the
jaundice is due to liver function
impairment
 Examples of disorder causing hepatic
jaundice:
 Gilbert’s Syndrome
 Impaired cellular uptake of bilirubin in
hepatocytes
 No conjugation because B1 is not able
to enter the hepatocytes
 Increased unconjugated bilirubin in
the blood
 Crigler-Najjar Syndrome
 Impaired conjugation due to absence
of UDPGT
 Increased unconjugated bilirubin in
the blood
 2 types:
 Type 1 – complete absence of
UDPGT
 Type 2 – partial deficiency of
UDPGT only
 Dubin-Johnson Syndrome
 Failure to excrete conjugated
bilirubin from liver cells to the bile
(B2 leak out in the circulation)
 Increased conjugated bilirubin in the
blood
 Deficiency of canalicular multridrug
resistance/multispecific organic
anionic transporter protein (MDR2/
cMOAT)
 B2 that circulates in the blood is
bound to albumin
 Delta Bilirubin – B2 bound to albumin
 Dark-stained granules in liver biopsy
samples
 Rotor Syndrome
 Clinically similar to Dubin-Johnson
syndrome
 Increased conjugated bilirubin in
blood
CLIN CHEM | LIVER FUNCTION TRISHA LORAINNE R. VILLOCENO

 Due to reduced conc. or activity of o Principle: Van den Berg reaction –

intracellular binding proteins such as diazotization of bilirubin to produce
ligandin azobilirubin
 Physiologic Jaundice of the Newborn o Only conjugated bilirubin is directly
 Occurs in premature infants due to measured with the Diazo reaction
absence of UDPGT enzyme
o Requires the use of accelerators to
 UDPGT enzyme – last to be activated
measure unconjugated bilirubin –
in prenatal life
 Increased unconjugated bilirubin in
accelerators act as Solubilizer
the blood o With accelerators, total bilirubin is
 B1 may deposit in brain thus Fatal measure
 KERNICTERUS – build-up of o Unconjugated bilirubin = Total bilirubin –
unconjugated bilirubin in the brain and conjugated bilirubin
nerve cells o Measurement is done first w/o
Post-hepatic Jaundice accelerator to measure conjugated
 Occurs when there is biliary obstruction bilirubin
(ex. Due to bile stones, tumor, biliary o Add accelerator and measure again after
cirrhosis etc.) 15 mins to get total bilirubin (allow
 Flow of B2 to the bile canaliculi is solubilization)
obstructed o Reference Values:
 B2 leaks out to the circulation Total bilirubin 0.2 – 1.0 mg/dL (3-
 Increased conjugated bilirubin in the 17 umol/L)
blood Conjugated 0.0-0.2 mg/ dL (0-3
 Clay-colored or gray-colored stool: bilirubin umol/L)
bilirubin does not reach the intestine Unconjugated 0.2-0.8 mg/ dL (3-
bilirubin 14 umol/L)
Conversion factor 17.1
LIVER FUNCTION TESTS
o Two methods: Malloy-Evelyn & Jendrassik
A. BILIRUBIN and Grof
o Test for conjugation and excretory Malloy-Evelyn
function  Accelerator: 50% methanol
o Specimen: Serum/Plasma (non-hemolyzed  Performed at pH 1.2 (acidic)
and non-lipemic)  Final reaction: Red purple azobilirubin
o Fasting specimen is preferred, but nor  Measured at 560 nm
required Jendrassik-Grof
o Must be protected from light since  Accelerator: Caffeine sodium benzoate or
bilirubin is photosensitive caffeine benzoate acetate (caffeine
o If exposed to ligh, bilirubin values may benzoate)
reduce by 30-50% per hour  Performed at alkaline pH (alkaline
o Store at: tartrate)
Room temp – 2 days  Uses ascorbic acid – terminates reaction
4oC – 1 week w/ diazo reagent
-20 oC – indefinite  Final reaction: Blue azobilirubin
CLIN CHEM | LIVER FUNCTION TRISHA LORAINNE R. VILLOCENO

 Measured at 600 nm
 Most commonly used method
 More sensitive than Malloy-Evelyn

B. ALBUMIN/TOTAL PROTEIN
o Test for synthesis function
o Decreased serum albumin/total protein
levels may be a result of decreased liver
protein synthesis

C. PROTHROMBIN TIME
o Test for synthesis function
o Liver is responsible for synthesizing
coagulation factors
o Increased prothrombin time = decreased
synthesis function

D. AMMONIA
o Test for detoxification function
o Useful in detecting: Hepatic failure,
Hepatic coma, Reye syndrome

E. LIVER ENZYMES
o Play a vital role in assessing liver function
and in differentiating hepatocellular from
obstructive liver disease
o Any injury to liver resulting in cytolysis or
necrosis will cause the release of liver
enzymes in the circulation
o High levels of liver enzymes in circulation
= liver damage