Liver function test

• Laboratory tests often called as liver function

tests are useful in the evaluation and treatment
of patients with hepatic dysfunction.
• LFT’s are the sensitive noninvasive methods of
screening for the presence of liver dysfunction.
This is particularly important for anicteric
patients who may have unsuspected disorder,
such as viral hepatitis, chronic active hepatitis,
cirrhosis, or partial bile duct obstruction
 BILIRUBIN
• Bilirubin is a yellow compound that occurs in
the normal catabolic pathway that breaks
down heme in vertebrates. This catabolism is
a necessary process in the body's clearance of
waste products that arise from the destruction
of aged red blood cells.
 BILIRUBIN
• Serum bilirubin
– Total bilirubin
– Direct Bilirubin
– Indirect bilirubin
• Urine bilirubin
• Urobilinogen
 AMINOTRANSFERASES
• The aminotransferases (formerly transaminases)are the
most frequently utilized and specific indicators of
hepatocellular necrosis.
• These enzymes- aspartate aminotransferase(AST, formerly
serum glutamate oxaloacetic transaminase-SGOT) and
alanine amino transferase(ALT, formerly serum glutamic
pyruvate transaminase-SGPT)catalyze the transfer of the a
amino acids of aspartate and alanine respectively to the a
keto group of ketoglutaric acid.
• ALT is primarily localized to the liver but the AST is
present in a wide variety of tissues (heart, skeletal
muscle, kidney, brain and liver).
• AST : alanine + a ketoglutarate = oxaloacetate
+
Glutamate.
• ALT: alanine + a ketoglutarate = pyruvate +
Glutamate.
Normal values of ALT and AST range from 9 to
40 IU/L and 10 to 35 IU/L
 ALKALINE PHOSPHATASE
• Alkaline phosphatases are a family of zinc
metaloenzymes, with a serine at the active center; they
release inorganic phosphate from various organic
orthophosphates and are present in nearly all tissues.
• In liver, alkaline phosphatase is found histochemically in
the microvilli of bile canaliculi and on the sinusoidal
surface of hepatocytes.
• Alkaline phosphatase from the liver, bone and kidney
are thought to be from the same gene but that from
intestine and placenta are derived from different genes.
 NORMAL RANGE 30 to 120 IU/L
Average values of alkaline phosphatase vary with
age and are relatively high in childhood and
puberty and lower in middle age and higher again
in old age. Males usually have higher values as
compared to females.
• Highest levels of alkaline phosphatase occur in
cholestatic disorders. Elevations occur as a result
of both intrahepatic and extrahepatic obstruction
to bile flow and the degree of elevation does not
help to distinguish between the two. Alkaline
phosphatase levels are likely to be very high in
EHBA.
 Renal function tests
• Glomerular function tests.
• Tubular function tests.
• Assessment of renal plasma flow.
• Blood / serum analysis.
• Urine analysis.

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 Glomerular function tests
● GFR cannot be measured directly.
● Large variation between individuals with large spread of
normal values.
● Causes of interpatient variability include:
Body size: GFR conventionally factored by 1.73 m2.
Sex: GFR approximately 8% higher in males.
Age: age-related decline in GFR, 0.75 to 1.0 mL/min/1.73 m2
Protein intake: GFR higher in patients on high-protein diet.
Diurnal variation: values tend to be about 10% higher in
afternoon than at night.

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Clearance (C): The rate at which an indicator substance is
removed from plasma per unit concentration; specifies a volume from
which all of a substance is removed per unit time.
● For a substance Z cleared by renal elimination:
Cz=UzxV ⁄ Pz
Where, Uz is urinary concentration of z,
Pz is plasma concentration of Z,
V is urine flow rate.
● If substance z is freely filtered and only excreted by GFR, then:
GFR= UzxV/Pz
● Thus, plasma concentration of indicator is inversely related to GFR and
GFR can be assessed from plasma concentration.
● Requires an ideal filtration marker to ensure that elimination of
substance is completely dependent on GFR .
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Characteristics of an IdealMarker for GFRMeasurement
• Constant rate of production (or for exogenous marker
can be delivered intravenously at a constant rate).
• Freely filterable at the glomerulus (minimal protein
binding)
• No tubular reabsorption
• No tubular secretion
• No extra renal elimination or metabolism
• Availability of an accurate and reliable assay
• For exogenous marker: safe, convenient, readily
available, inexpensive, and does not influence GFR
(physiologically inert).
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Markers used to determine GFR

Endogenous markers Exogenous markers

•Creatinine •Inulin
•Urea •Mannitol
•CystainC •Sorbital
•Dulcitol
•Sodiumthiosulphate

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 Creatinine clearance
• An endogenous amine produced as a result of
muscle catabolism.
• Normal value:120-145ml/min.
• Clinical inference:
20-50ml/min-moderate RF.
 10ml/min-severe renal impairement.

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 Urea clearance
• One of the first indicators used to measure GFR.
• If urine output is more than 2ml/min,
Maximum clearance:75ml/min
• If urine output is less than 2ml/min,
Standard clearance:54ml/min
are calculated.
• Clinical inference:
below 60% of the normal indicate impaired
GFR.
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 Inulin clearance
• Inulin (molecular weight 5,000 d).
• Fructose polymer, freely filtered, neither
reabsorbed nor secreted by tubules.
• Physiologically inert.
• Normal value:130ml/min.
• Clinical inference:
Decrease indicates impairment of GFR.

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 Tubular function tests

• Urine concentration test.

• Urine dilution test.
• Urine acidification test.
• Phenol sulphonephthalein test.

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 Phenol sulphonephthalein test
• Not filtered by the glomeruli but secreted by
the tubular cells into the tubular fluid.
• Normal persons excrete
20-25% of injected dose within 15 minutes ,
55-70%within 70 minutes.
• Clinical inference:
excretion decreases in Hydronephrosis,
Polycystic disease.
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 Assessment of renal plasma flow
● Derived from rate of clearance of a marker
that is totally extracted from plasma after
first pass through kidney; this yields RPF.
●P-amino hippurate (PAH) is most widely
used marker.
● Mean values of ERPF are
650 mL/min/1.73 m2 in males
600 mL/min/1.73 m2in females
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 Blood/serum analysis

• Serum Creatinine.
• Blood urea.

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 Serum Creatinine
Determined by
• Jaffe reaction.
• Enzymatic kinetic alkaline picrate method.
• Specific indicator of renal dysfunction.
• Normal value:0.6-1.5mg/100ml.
• Clinical inference:
Elevated in renal impairment.

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 Blood urea
• Normal value: 20-45mg/100ml.
• Clinical inference:
Elevated in chronic Glomerular nephritis,
Pyelonephritis,
Urinary tract obstruction,
Dehydration&shock,
Hematemesis,
Increased tissue breakdown.
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 Urine analysis

• Physical examination.
• Chemical examination.
• Microscopic examination.

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Parameter Normal Clinical inference
Volume 1000-2000ml/day Increases in
Diabetes mellitus
Physical examination Diabetes insipidus
Chronic renal failure

Appearance Clear and transparent Turbid in presence of

cells,casts,crystals…..
Colour Amber yellow Greenish yellow-bilepigment
Red-haemoglobin
Odour Characteristic aromatic Ammonical-UTI
Fruity-ketosis
Reaction Vary from slightly acidic to Acidosis-DM,starvation
slightly alkaline Alkalosis-vomiting,UTI

Specific gravity 1.012-1.024 Increases in

Acute glomerulo nephritis
DM,Dehydration
Decreases in
Chronic glomerulo nephritis
DI

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 Chemical examination
Constituent Test Associated disorder(s)

Albumin Heat coagulation test Kidney damage

Hemoglobin Benzidine test Damage to kidneys (or)

urinary tract

Glucose Benedict’s test Diabetes mellitus, renal

glycosuria`
Specific detection of Glucose Glucose oxidase test Diabetes mellitus

Ketone bodies Rothera’s test Diabetes mellitus

Starvation
Bile salts Hay’s test Obstructive jaundice

Bile pigments Gmelin’s test Obstructive jaundice

Hepatic jaundice
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