Evaluation of Liver Injury

Mark
Mark J.
J. Czaja
Czaja

Liver
Liver Research
Research Center
Center
Albert
Albert Einstein
Einstein College
College of
of Medicine
Medicine
Bronx,
Bronx, N.Y.
N.Y.
 Liver Function Tests
• Alanine
Alanine aminotransferase
aminotransferase (ALT)
(ALT)
• Aspartate
Aspartate aminotransferase
aminotransferase (AST)
(AST)
• Lactate
Lactate dehydrogenase
dehydrogenase (LDH)
(LDH)
• Alkaline
Alkaline phosphatase
phosphatase
• Bilirubin
Bilirubin
• Albumin
Albumin
Mechanisms of Liver Dysfunction

• Direct
Direct cellular
cellular injury
injury
• Blockage
Blockage in
in bile
bile flow
flow
• Impaired
Impaired blood
blood flow
flow
Direct Cellular Injury - HCV Infection
Blockage in Bile Flow - Biliary
Atresia
Impaired
Impaired Blood
Blood Flow
Flow -- CHF
CHF
 Consequences of Liver Injury
liver cell injury

liver cell death

proliferation matrix deposition

sufficient inadequate altered architecture

recovery liver failure cirrhosis

 Types of Liver Tests

• True tests
tests of liver function
• Biochemical markers
markers of liver injury
injury
• Biochemical markers
markers of specific
specific
liver
liver diseases
 Testable Biochemical Liver
Function
• Ability
Ability to
to transport
transport organic
organic anions
anions
• Capacity
Capacity toto metabolize
metabolize certain
certain substances
substances
• Capability
Capability to
to synthesize
synthesize various
various proteins
proteins
Steps in Organic Anion Transport

• Delivery
Delivery and
and uptake
• Metabolic
Metabolic alteration
alteration
• Secretion
Secretion and
and excretion
excretion
 Bilirubin
• Tetrapyrole
Tetrapyrole
• Toxic in neonates - kernicterus
• Derived from:
from:

 Senescent
Senescent RBC
RBC (70-80%)
(70-80%)
 Hemoproteins (20-30%)

Hemoproteins (20-30%)
 Ineffective erythropoiesis

Ineffective erythropoiesis
 Bilirubin Formation

heme biliverdin
heme oxygenasebiliverdin bilirubin
reductase

Transport: hydrophobic due to internal H-bonding

circulates bound to albumin
 Bilirubin Metabolism
Plasma Hepatocyte Bile

Alb
UCB BMG BMG
UCB glucuronyl
BMG transferase BDG BDG
ligandin
BDG
 Bilirubin Elimination
 Intestine  Urine
Urine
• BMG
BMG (20%)
(20%) ++ • BMG
BMG and
and BDG
BDG
BDG
BDG (80%)
(80%) • No
No UCB
UCB
+UCB
+UCB (trace)
(trace)
• Deconjugated
Deconjugated to to
urobilinogen
urobilinogen
• Excreted
Excreted oror reab-
reab-
sorbed
sorbed (20%)
(20%)
 Measurement of Serum
Bilirubin
• Normal
Normal concentration
concentration << 11 mg/dl
mg/dl
• Conjugated
Conjugated << 5%
5%
• Jaundice
Jaundice if
if >> 33 mg/dl
mg/dl
• Detected
Detected by
by diazo
diazo reaction
reaction -- cleaved
cleaved
to
to colored
colored azo-dipyrole
azo-dipyrole

 Conjugated
Conjugated reacts
reacts rapidly
rapidly (direct)
(direct)

 Unconjugated
Unconjugated reacts
reacts slowly
slowly (indirect)
(indirect)
Differential Diagnosis I
• Prehepatic
Prehepatic
• Intrahepatic
Intrahepatic

 Congenital
Congenital
 Acquired

Acquired
• Posthepatic
Posthepatic
 Differential Diagnosis II
• Unconjugated
Unconjugated hyperbilirubinemia
hyperbilirubinemia

 Increased
Increased bilirubin
bilirubin production
production (hematological)
(hematological)

 Decreased
Decreased uptake
uptake (drug)
(drug)

 Decreased
Decreased conjugation
conjugation (congenital)
(congenital)
• Conjugated
Conjugated hyperbilirubinemia
hyperbilirubinemia

 Congenital
Congenital

 Drug
Drug

 Liver
Liver disease
disease

 Biliary
Biliary obstruction
obstruction
 Inherited Disorders Causing
Unconjugated Hyperbilirubinemia
• Crigler-Najjar
Crigler-Najjar syndrome
syndrome

 Type
Type 11 –– absent
absent GT
GT

 Type
Type 22 –– reduced
reduced GT
GT activity
activity
• Gilbert
Gilbert’’ss syndrome
syndrome –– reduced
reduced GT
GT
activity
activity due
due to
to genetic
genetic defect
defect in
in
TATAA
TATAA element
element of
of GT
GT promoter
promoter
 Inherited Disorders Causing
Conjugated Hyperbilirubinemia

• Dubin-Johnson
Dubin-Johnson syndrome
syndrome ––
mutations
mutations in in multidrug
multidrug resistance
resistance
associated
associated protein
protein 22 (MRP2)
(MRP2)
• Rotor
Rotor’’ss syndrome
syndrome –– genetic
genetic defect
defect
Hepatic Metabolic Capacity
• Clearance
Clearance must
must depend
depend on
on total
total
functional
functional mass
mass or
or metabolic
metabolic activity
activity
• Hepatic
Hepatic drug
drug metabolism
metabolism -- [[14
14C]amino-
C]amino-
pyrine
pyrine breath
breath test
test
• Galactose
Galactose elimination
elimination
• Not
Not used
used clinically
clinically
 Hepatic Synthetic Capacity

• Most
Most major
major plasma
plasma proteins
proteins are
are made
made in
in
the
the liver
liver
• Decreased
Decreased hepatocytes
hepatocytes == decreased
decreased
protein
protein synthesis
synthesis and
and release
release
• Albumin
Albumin andand coagulation
coagulation factors
factors are
are
clinically
clinically important
important
 Albumin
• 50%
50% of
of all
all synthesized
synthesized hepatic
hepatic
protein
protein
• Determinant
Determinant of of plasma
plasma oncotic
oncotic
pressure
pressure
• Important
Important transport
transport protein
protein
 Serum Albumin Levels

• Long
Long half-life
half-life of
of 20
20 days
days
• Large
Large hepatic
hepatic synthetic
synthetic reserve
reserve
• Decreased
Decreased with
with persistent,
persistent, large
large injury
injury
• Decreased
Decreased in
in chronic
chronic liver
liver disease
disease
• Poor
Poor prognostic
prognostic sign
sign
 Non-hepatic Causes of
Hypoalbuminemia
• Severe
Severe malnutrition
malnutrition
• Renal
Renal or
or GI
GI loss
loss

 Glomerulopathy,
Glomerulopathy, HIV
HIV enteropathy
enteropathy
• High
High catabolism
catabolism

 Infections,
Infections, burns
burns
 Coagulation Factors

• Half-lives
Half-lives of
of hours
hours to
to days
days
• Liver synthesizes I, II, V, VII,
IX, and
and X
X
• Large
Large synthetic
synthetic reserve
reserve
 Prothrombin Time (PT)
• PT
PT detects
detects abnormalities
abnormalities inin I,I, II,
II, V,
V,
VII
VII and
and XX (extrinsic
(extrinsic pathway)
pathway)
• PT
PT is
is increased
increased in
in liver
liver disease
disease
• Best
Best prognostic
prognostic indicator
indicator

 Acute
Acute liver
liver disease
disease

 Chronic
Chronic liver
liver disease
disease
 Non-hepatic Causes of
Elevated PT
• Congenital
Congenital coagulation factor
factor
deficiencies
deficiencies
• Consumptive
Consumptive coagulopathies
coagulopathies
• Vitamin
Vitamin K deficiency (II, VII, IX,
IX, X)
X)
To Rule Out Vitamin K Deficiency

• Any
Any patient
patient with
with an
an elevated
elevated PTPT
• Parental
Parental vitamin
vitamin KK for
for 33 days
days
• Normalization
Normalization ofof PT
PT -- vitamin
vitamin K
K
deficiency
deficiency
• Failure
Failure to
to normalize
normalize -- hepatocellular
hepatocellular
disease
disease
 Serum Immunoglobulins

• Not
Not produced
produced by
by hepatocytes
hepatocytes
• Frequently
Frequently elevated
elevated in
in liver
liver disease
disease
• Secondary
Secondary to
to inflammatory
inflammatory process
process
• ?? produced
produced by
by antigen
antigen shunting
shunting
 Biochemical
Markers of Liver
Injury
 Liver Enzymes
• Low levels always present in serum
• Leak
Leak out from cell
cell after injury
• Very sensitive
• Magnitude of abnormality does not
correlate
correlate well
well with
with degree
degree of
of injury
injury
 Aspartate Aminotransferase
(AST)
• Serum
Serum glutamic-oxaloacetic
glutamic-oxaloacetic
transaminase
transaminase (SGOT)
(SGOT)
• Transfers an 
Transfers an -amino
-amino group
group of
of aspartate
aspartate
to 
to -keto
-keto group
group of
of ketoglutaric
ketoglutaric acid
acid
• Present
Present in
in skeletal
skeletal muscle,
muscle, kidney,
kidney, brain
brain
 Alanine Aminotransferase
(ALT)
• Serum
Serum glutamic-pyruvic
glutamic-pyruvic transaminase
transaminase
(SGPT)
(SGPT)
• Transfers an 
Transfers an -amino
-amino group
group of
of alanine
alanine
to 
to -keto
-keto group
group of
of ketoglutaric
ketoglutaric acid
acid
• Present
Present principally
principally in
in liver
liver
 AST and ALT
• Elevated
Elevated inin most
most liver
liver diseases
diseases
• Highest
Highest levels
levels are
are in
in acute
acute liver
liver
diseases
diseases
• Only
Only slight
slight elevations
elevations inin chronic
chronic
liver
liver diseases
diseases
• Usually
Usually increase
increase in
in parallel
parallel
 AST/ALT in Alcoholic
Hepatitis

• Transaminases
Transaminases rarely
rarely exceed
exceed 300
300
• AST:ALT >2
>2
 Factors Affecting AST/ALT

• Depressed
Depressed by
by pyridoxine
pyridoxine (vit.
(vit. B
B66))
deficiency
deficiency
• Decreased
Decreased by
by uremia
uremia and
and renal
renal dialysis
dialysis
AST/ALT Controversies
• Should
Should lower
lower normal
normal limits
limits be
be
used
used in
in females?
females?

 Females
Females << 30
30 vs.
vs. males
males << 40
40
• Are
Are the
the normal
normal limits
limits too
too high?
high?

 Females
Females << 20
20 and
and males
males << 30
30
Lactate Dehydrogenase
(LDH)

• Component
Component of
of classic LFT’’ss
classic LFT
• Highly non-specific
 Tests of Impaired Hepatic
Excretion
Increased In
• Cholestasis
Cholestasis
• Intra-hepatic
Intra-hepatic biliary
biliary tract
tract obstruction
obstruction
• Extra-hepatic
Extra-hepatic biliary
biliary obstruction
obstruction
 Alkaline Phosphatase
• Hydrolyzes
Hydrolyzes phosphate
phosphate esters
esters at
at
alkaline
alkaline pH
pH
• Also
Also present
present inin bone,
bone, kidney,
kidney, placenta,
placenta,
intestine
intestine
• Mainly
Mainly liver
liver and
and bone
bone in
in adults
adults
• Increased
Increased inin children
children from
from bone
bone growth
growth
• Placental
Placental form
form during
during pregnancy
pregnancy
Elevated Alkaline Phosphatase

• Can
Can occur
occur inin any
any liver
liver disease
disease
• Highest
Highest with
with cholestasis
cholestasis or
or biliary
biliary tract
tract
obstruction
obstruction
• Elevated
Elevated inin infiltrative
infiltrative diseases
diseases
• Due
Due to
to increase
increase synthesis
synthesis and
and secretion
secretion
Alkaline Phosphatase Isoenzymes
Heat
Source Inactivation 5' NT GGTP

Liver Moderate + +
Bone Rapid - -
Placenta Slow - -
Intestine Slow - -
 5'-Nucleotidase

• Hydrolyzes
Hydrolyzes 55'-'- adenosine
adenosine monophosphate
monophosphate
• Mainly
Mainly present
present in
in liver
liver
• Increases
Increases along
along with
with alkaline
alkaline phosphatase
phosphatase
 -Glutamyl Transpeptidase
(GGTP)
• Transfers -glutamyl
Transfers -glutamyl groups
groups
• Widely
Widely distributed
distributed
• Sensitive
Sensitive correlate
correlate to
to alkaline
alkaline phosphatase
phosphatase
• Non-specific
Non-specific (alcoholism,
(alcoholism, MI,
MI, DM,
DM,
pancreatic
pancreatic disease,
disease, renal
renal failure)
failure)
Biochemical Markers
of Specific Liver
Diseases
Etiology-specific Liver Tests

• Viral
Viral hepatitis
hepatitis serologies
serologies
• Serum
Serum ferritin
ferritin level
level
• Ceruloplasmin
Ceruloplasmin levellevel
• Alpha
Alpha11-antitrypsin
-antitrypsin level
level
• Antimitochondrial
Antimitochondrial antibody
antibody titer
titer
 Viral Hepatitis Serology

• HAV – anti-HAV IgM and IgG

• HBV –– HBsAg,
HBsAg, anti-HBsAg,
anti-HBsAg,
and
and anti-HBcAg
• HCV –– anti-HCV,
anti-HCV, HCV
HCV RNA
RNA
 Serum Ferritin

• Widely
Widely distributed
distributed storage
storage protein
protein
• Levels
Levels reflect
reflect body
body iron
iron stores
stores
• Elevated
Elevated in
in primary
primary hemochromatosis
hemochromatosis
• Elevated
Elevated in
in acute
acute inflammation
inflammation and
and
cirrhosis
cirrhosis
 Serum Ceruloplasmin

• Copper-binding
Copper-binding protein
protein
• Decreased
Decreased inin 95%
95% ofof patients
patients
with Wilson’’ss disease
with Wilson disease
• 20%
20% of
of heterozygotes
heterozygotes have
have
decreased
decreased levels
levels
 11-Antitrypsin

• Inhibits serum trypsin

trypsin
• Major component
component ofof 
11-globulin
-globulin
• Deficiency
Deficiency cause
cause of
of neonatal
neonatal
hepatitis
Antimitochondrial Antibody
(AMA)
• Directed
Directed against
against mitochondrial
mitochondrial
enzyme
enzyme pyruvate
pyruvate
dehydrogenase
dehydrogenase complex
complex
• Positive
Positive in
in 90%
90% ofof patients
patients with
with
primary
primary biliary
biliary cirrhosis
cirrhosis
 Interpretation of Abnormal
LFT’s
• Examine
Examine multiple
multiple tests
tests
• Consider
Consider non-hepatic
non-hepatic causes
causes
• Determine
Determine the
the most
most abnormal
abnormal tests
tests
 Hepatocellular vs.
Cholestatic
Test Hepatocellular Cholestatic
ALT/AST 2-3 NL-1
Alk Phos NL-1 2-3
Bilirubin NL-3 NL-3
Albumin NL-3 NL
PT NL-3 NL
 Case 1
25 yo IVDA c/o 1 week of nausea,
vomiting, and myalgias. Physical
exam revealed jaundice.
• ALT
ALT 2045
2045 (15-45)
(15-45) • Bili
Bili 3.9
3.9 (0.1-1.0)
(0.1-1.0)
• AST
AST 2300
2300 (15-45)
(15-45) • Alb
Alb 4.2
4.2 (3.5-5.5)
(3.5-5.5)
• Alk
Alk Phos
Phos 273
273 • PT
PT 11.5
11.5 (10-12)
(10-12)
(50-150)
(50-150)
 Hepatocellular W/U
H&P
EtOH, medications, transfusions

Risk for viral Risk factors Autoimmune

hepatitis for NASH features

Etiology-specific LFT’s

USG and liver biopsy

HBV Infection - HBcAg Staining
 Case 2
67 yo c/o several months of weight loss,
and 1 week of nausea, vomiting, and
myalgias. Physical exam revealed
cachexia and jaundice.

• ALT
ALT 7575 (15-45)
(15-45) • Bili
Bili 10.2
10.2 (0.1-1.0)
(0.1-1.0)
• AST
AST 115
115 (15-45)
(15-45) • Alb
Alb 4.2
4.2 (3.5-5.5)
(3.5-5.5)
• Alk
Alk Phos
Phos 650
650 • PT
PT 11.0
11.0 (10-12)
(10-12)
(50-150)
(50-150)
 Cholestatic W/U
H&P
medications, gallstones, weight loss

USG
normal dilated ducts

AMA ERCP

liver biopsy
Pancreatic Carcinoma - ERCP