Organ Function Test

• Specific biochemical tests done in the laboratory for proper

assessment of functions of the organs.
• Any abnormality in the tissue may seriously impair the organ function.
• It is important for medical team to do these tests to check how vital
body organs are currently working (function).
LIVER FUNCTION TEST
 LFT
• Liver function tests are blood tests used to help diagnose and
monitor liver disease or damage.
 FUNCTIONS OF LIVER
1. Metabolic functions
Metabolism of carbohydrate, lipid, protein, minerals and vitamins

2. Secretory functions
Formation and secretion of bile into the intestine

3. Excretory functions
Exogenous dyes e.g. Bromsulphthalein (BSP) and Rose Bengal dye
are exclusively excreted through liver
4. Protective and Detoxification
Ammonia converted to urea
Xenobiotics -elimination of drugs, hormones
Phagocytosis by Kupffer cells

5. Hematological functions
Synthesis of plasma proteins and clotting factors
Erythropoiesis in embryo

6. Storage functions
Glycogen, Vit.A, & Vit.B12 etc
INDICATIONS
• Jaundice
• Screen for liver infections, such as hepatitis.
• Alcoholic liver disease.
• Monitor the progression of a liver disease, particularly
scarring of the liver (cirrhosis)
• Monitor possible side effects of medications .
 Routine markers used
 Serum total and direct bilirubin
Enzymes: ALT, AST, ALP, GGT & 5’NT
Serum total protein & A/G ratio
Prothrombin time (PT)
 Urine analysis for bile pigments and salts
CLASSIFICATION OF LFT
A. Tests for liver excretion function: Serum Bilirubin with fractionation,
Urinary bile pigment and bile salt
Dye excretion test: Bromosulphthalein (BSP), Rose bengal
B. Liver enzymes: ALT & AST (markers of liver injury), ALP, GGT & NT
(cholestasis markers)
C. Tests for synthetic function of liver: T. Protein, Albumin, A/G ratio & blood
ammonia
D. Tests for metabolic liver diseases: Ceruloplasmin, α1 antitrypsin (AAT), Alpha
fetoprotein (AFP)
E. Markers of hepatic fibrosis: Serum hyaluronic acid, Matrix metalloproteinase,
TGF-β
1.Tests based on bilirubin metabolism (SECRETORY FUNCTION)

• Bilirubin is the excretory end product of heme catabolism.

• Approx. 250 – 350 mg of bilirubin is produced daily.
• Bilirubin metabolism in liver can be divided into 3 processes.
Uptake
Conjugation
secretion
 Hyperbilirubinemia causes Jaundice
Jaundice/ icterus
• Defined as Yellowish discoloration of tissue (skin, sclera
and mucous membrane) resulting from the deposition of
bilirubin (normal up to 1.2 mg/dL) in tissues.
• Jaundice is commonly classified as haemolytic
(prehepatic), hepatic and obstructive/post hepatic
types.
• Jaundice is usually apparent clinically when plasma
bilirubin reaches 2 to 3 mg%.
• Conjugated (Direct): Normal serum range 0.2 – 0.4
mg%.
Bil-T=
• Unconjugated/ indirect (α) bil. + conjugated/direct bil.
• Direct bil.= Monoconjugated /β + Diconjugated /γ + δ- bilirubin
(irreversibly bound to protein).
• Bil- Diglucuronide/ Bil- monoglucuronide in bile is 4:1.
• Up to 30%, (0.3 mg/dL), of the total bilirubin (normal 0.2 to 1.2
mg/dl) may be direct (conjugated) bilirubin.
 Classification of jaundice

• Hemolytic / Pre hepatic jaundice

Causes- Sickle cell disease, malaria, severe iron deficiency
• Hepatocellular / Hepatic jaundice
Viral hepatitis, alcohol, drug toxicity
• Obstructive / post hepatic jaundice
Viral hepatitis, Alcoholic hepatitis, gall stone, gall bladder carcinoma
SOME CAUSES OF UNCONJUGATED
AND CONJUGATED
HYPERBILIRUBINEMIA
 Van den Bergh Reaction

• Used to measure bilirubin levels in blood.

• The test is based on the reaction between bilirubin and VD Bergh’s diazo
reagent.

• Purple colored “azo bilirubin” is formed.

• Types of responses:
1. Direct positive – conjugated hyperbilirubinemia (response within 30 seconds)
Obstructive jaundice
2. Indirect positive– unconjugated hyperbilirubinemia - Purple compound
obtained only after addition of methanol.
Hemolytic jaundice
3. Biphasic – Purple color is obtained immediately, further intensified by addition
of methanol.
Hepatic jaundice
B. Role of Enzymes in the diagnosis of liver diseases

Enzymes Normal Interpretation in liver diseases

AST/ SGOT 0 to 40 U/L In most liver diseases serum AST<ALT.
Exceptions are alcoholic hepatitis (AST/ALT >2, suggestive), liver cirrhosis &
carcinoma (AST/ALT>1) & NASH.
AST rarely exceeds 300 U/L in alcoholic hepatitis cases.
ALT/SGPT 0 to 40 U/L ALT is more liver specific.
> 500 U/L most often found in viral hepatitis, ischemic liver injury and toxin-
induced liver damage.

ALP 40-129 U/L Moderate (<3 fold) increase or even normal ALP level is seen in hepatic
diseases.
ALP ˃ 3 fold may be found in biliary obstruction.

GGT Female <40 Highest level (5-30 times) found in liver carcinoma. Moderate elevation
U/L Male detected in infective hepatitis.
<70 U/L Primary importance is limited to rule out bone disease.
Elevated level is found in alcoholic hepatitis and a sensitive marker of alcohol
abuse.
5’NT 3–9 IU/L Highly specific for hepatobiliary disease & not affected by bone diseases.
Marked increased (3-6 folds) in biliary obstruction.
 Blood tests to distinguish between haemolytic, hepatic and
obstructive jaundice
Test Prehepatic/ haemolytic Hepatic jaundice Post hepatic/ obstructive
jaundice jaundice
Unconjugated bilirubin Highly raised (++) as it Elevated (+) due to reduced Normal
(van den Bergh test- exceeds the conjugation ability conjugation by liver.
indirect positive) of liver.

Conjugated bilirubin Normal or mildly increased. Elevated (+) due to the Markedly elevated (++)
(van den Bergh test- cholestasis by inflamed
direct positive) cells. So biphasic rise of
both fraction of bilirubin.

ALT and AST AST may rise due to Both the enzymes are Rise may be mild to
hemolysis. markedly elevated (++). moderate or normal.
ALT> AST in most of the
cases.

ALP Normal Mild to moderate elevation Very high (up to 10-12

(2-3 times of URL) is usual. times). Should be correlated
with serum 5’NT or GGT
 Urine test to distinguish between haemolytic, hepatic and obstructive jaundice

Test Prehepatic/ haemolytic Hepatic jaundice Post hepatic/ obstructive

jaundice jaundice

Conjugated bilirubin Absent Present but usually less Present. Excretion of direct
(Fouchet's test) than post hepatic jaundice. bilirubin is low due to bile
duct obstruction.
Urobilinogens (Ehrlich Present (+++). High UBG Initially UBG is increased Absent due to obstruction
test) synthesis leads to increased and then the level to bile flow.
excretion. decreased due to
diminished synthesis.
Bile salt (Hay's test) Absent Usually absent. It may be Present. Obstruction in the
present due to microbiliary biliary passages leads to
obstruction their excretion in urine.
C. Tests for synthetic function of liver:

a. Serum Total proteins:

Changes found in parenchymal liver injury.
Serum albumin is characteristically decreased and high gamma
globulin is seen.
b. Serum albumin (t1/2= 20 days): Indicates chronicity as well as
severity.
A/G ratio (normal is 1.2-1.6:1) is less than one in liver cirrhosis.
c. Prothrombin time (PT):
Marker of severity and is better than albumin.
It is the most important prognostic marker in acute liver disease.
Normal value is 10-14sec.
It is usually first function test to be increased when chronic hepatitis
progresses to cirrhosis.
d. Alpha-1-antitrypsin (AAT)
It inactivates elastage and collagenase.
Low level is found in liver cirrhosis.
e. Blood ammonia
Rise in advanced liver disease like hepatic encephalopathy and
urea cycle disorder.
D. Tests for metabolic liver disease
• AFP (alpha-fetoprotein) – very high level in liver cancer.
• Ceruloplasmin- Decrease level in Wilson’s disease.
• Ferritin- High level in liver disease.
E. Tests for detoxification function of liver:
• Measurement of Hippuric acid synthesis in liver.
• Decrease Hippuric acid excretion in urine indicates liver damage.
F. Immunological tests:
 Increase IgG level in chronic liver disease and autoimmune hepatitis.
 High IgM is seen in primary biliary cirrhosis and high IgA found in
alcoholic hepatitis.
 G. Tests based on metabolic functions of liver

1. Carbohydrate metabolism
Galactose tolerance test
• Done to determine the liver's ability to convert galactose into glycogen.
• Impaired in liver cell injury.
2. Protein metabolism

• Determination of blood Ammonia

• Impairment in ammonia removal from blood, rise is seen in parenchymal
liver diseases.
Interpretation of tests in jaundice
A. Isolated elevation of bilirubin
a. Conjugated/Direct hyperbilirubnemia (direct >15%)
Inherited conditions like Dubin-Johnson syndrome and Rotor's
syndrome.
b. Indirect hyperbilirubnemia (direct <15%): Hemolytic disorders,
ineffective erythropoiesis, inherited conditions (Crigler-Najjar types I
and II, Gilbert's syndrome)
B. Bilirubin and other tests elevated
a. AST or ALT elevated out of proportion to ALP (hepatocellular
pattern):
Viral hepatitis, alcoholic, drug toxicity (acetaminophen, rifampicin),
environmental toxins
b. ALP out of proportion to AST or ALT (cholestatic pattern): causes
are
i. Intrahepatic: Primary biliary cirrhosis, drugs like chlorpromazine,
malaria
ii. Extrahepatic: Pancreatic cancer, gallbladder cancer
• Urinary examination
Should be advised for the presence of bile pigments (bilirubin), bile
salts and urobilinogen for all jaundice patients.
A. Urinary Bilirubin: detected by Fouchet's test or Gmelin's test.
B. Urinary Urobilinogen: detected by Ehrlich's test.
C. Urine Bile Salts- detected by Hay’s test.
Algorithm for diagnosis of liver disease
 LQ
1. Write the biochemical tests to investigate a case of jaundice. (8) SOAU 09
2. A man aged 26 years was admitted to a hospital following few episodes of
nausea, vomiting and generalized malaise. On examination his urine was dark
and he had jaundice. The liver was enlarged and tender. Liver function test
revealed the following results. (2x5) SOAU 10
• Total serum bilirubin - 9 mg%
• SGOT (AST) - 400 IU/L
• SGPT (ALT) - 1500 IU/L
I. What is your most probable diagnosis?
II. What reactions are catalysed by AST and ALT?
III. Which other enzymes might have been elevated in plasma?
IV. How does total bilirubin relate to direct and indirect bilirubin?
V. What will happen to his serum albumin level if the disease becomes chronic?
3. A 45 year old man complained of severe pain in abdomen with deep
yellow urination and white coloured faeces.
On investigation, his total serum bilirubin was 20.7 mg/dl and
serum alkaline phosphates was 2045 units/L serum AST &
ALT values were normal.
Answer the following: 2x5 SOAU 13
(a) What is the diagnosis?
(b) Why the urine colour is dark yellow?
(c) What is the type of hyperbilirubinemia in the above case?
(d) What further investigations will confirm your diagnosis?
(e) What are the other types of hyperbilirubinemia?
4. What is jaundice? Enumerate the tests based on various function of
liver. Explain the role of Enzymes in the diagnosis of liver diseases.
5. What is Jaundice and what are the various types? Describe different
liver function tests for differential diagnosis of different types of
Jaundice. [3+12] SOAU Sup16
6. Discuss the various liver function tests. 15 UTKLU 17
7. Discuss the tests you will do in blood and urine to distinguish between
haemolytic, hepatic and obstructive jaundice. (6+4) KITS 10, KITS 16
8. A 57 years old man with stone in common bile duct was admitted in
the hospital. His plasma total bilirubin was 10mg%, direct bilirubin
8 mg% and indirect bilirubin 2 mg%. 3x5=15 UTKLU 08
a. What kind of jaundice he is suffering from?
b. What will happen when sulphur powder sprinkled over his urine
sample?
c. From what substance bilirubin is formed?
d. What is direct bilirubin?
e. Which serum enzyme is expected to be elevated in this patient?
SQ
1. Van den Berg test (2.5) SMBPU 17, (2) BERHMU 13
2. Liver function Test (LFT) (5) SOAU 16, (5) UTKLU 11
3. Serum alkaline phosphatase is increased in ______ liver disease.
(1) BERHMU 04
4. Urinary urobilinogen is increased in ______ type of jaundice. (1)
BERHMU 12
5. The defect in uptake of bilirubin by liver causes ______ disease.
(1) BERHMU 13
6. Name the enzyme raised in alcoholic liver disease. (1) SMBPU 11
7. Bilirubin conjugated with glycine becomes direct bilirubin. (T/F)
(1) BERHMU 07
8. Bile salts are increased in patient of haemolytic jaundice patients.
(T/F) (1) BERHMU 07