LIVER FUNCTION TESTS

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1 LIVER FUNCTION TESTS TtáxÜ `A TuwxÄté Å? c{w Assistant professor of Medical Biochemistry Zagazig University, Egypt University of Bisha, KSA 3/20/2018 of Clinical Medical Biochemistry and 24

2 Liver Functions Tests 1.Functions of human liver. 2. Major tests used in diagnosis of liver disorders. 3. Major changes in plasma enzymes and their 3/20/2018 indication in liver diseases. 4.Major pathological changes in liver. 5.Hepatic coma. 6. Jaundice. of Clinical Medical Biochemistry and 25

3 Liver is the master organ in the body, it serve all other organs Functions of liver: 1. Metabolism (Lipid, Proteins, Carbohydrates) 2. Storage (Glycogen, Vitamins, Vitamin B12) 3. Excretory function (Bilirubin, Cholesterol). 4. Detoxification (Phenbarbiton, Amonia, Steroid Hormones, Benzoic) 5. Hematological function (Blood formation, Blood volume, Blood coagulation). 3/20/2018 of Clinical Medical Biochemistry and 26 CAH: chronic active hepatitis

4 Anatomical over view Figure (1): liver Lobule 3/20/2018 of Clinical Medical Biochemistry and 27

5 Major tests used to diagnose liver functions Plasma enzymes Plasma proteins Serology ALT 1. Albumin (cirrhosis) 1. Anti mitochondrial. AST GGT ALP LDH 5` nucleosidase 2. (α, ᵦ, ɣ) globulins (Cholestasis) 3. Immunoglobulins(IGs) - IgG: chronic active hepatitis - IgA: portal cirrhosis - IgM: biliray cirrhosis, viral hepatitis Ab.(CAH, Biliray cirrhosis 2. Anti nuclear: autoimmune hepatitis 3. Anti smooth muscle: CAH 3/20/2018 of Clinical Medical Biochemistry and CAH: Chronic active hepatitis 28

6 Major changes in plasma enzymes and its indication in liver diseases (1) Serum ALT (sgpt)(n= up to 35 U/ml) It presents in high concentration In: 1. Liver 2. Skeletal muscles 3. Kidneys 4. Heart Causes of ALT increase Marked increase( times) 1. Viral hepatitis 2. Toxic liver hepatitis 3. Circulatory failure Moderate increase 1. Liver cirrhosis 2. Cholestatic jaundice 3. Liver congestion 4. Secondary to cardiac failure 5. Extensive trauma 3/20/2018 of Clinical Medical Biochemistry and 29

7 (2) Serum AST (sgot)(n= up to 40 U/ ml) It present in high concentration In: 1. Heart 2. Liver 3. Muscle 4. Kidenys Causes of AST increase Physiological increase In newborn its increase = 1.5 of normal level Artefacual increase Due to hemolysis of blood in lab. Led to its release Moderate increase 1. Liver cirrhosis 2. Cholestatic jaundice 3. Liver infiltration 4. Skeletal muscle disease 5. After trauma or surgery Marked increase ( times ) 1. Myocardial infraction 2. Viral hepatitis 3. Toxic liver cirrhosis 4. Circulatory failure due to - Shock - Hypoxia 3/20/2018 of Clinical Medical Biochemistry and 30

8 (3) Serum Alkaline Phosphatase (ALP) N= ( U/L) Presents in high concentration In: 1. Bone 2. Liver 3. Kidneys 4. Lactating mammary glands 5. Intestinal wall 6. Placenta Causes of ALP increase Physiological 1. Children until puberty 2.5 times of adult level 2. Pregnancy Bone diseases 1. Osteomalcia 2. Rickets 3. Bone carcinoma 4. Healing stage of bone fractures Liver diseases 1. Cholestatic jaundice* 2. Hepatitis 3. Cirrhosis 4. Tumors * * 5. Infiltration * * 3/20/2018 of Clinical Medical Biochemistry and 31

9 (4) Serum Lactate Dehydrogenase (LDH) N= ( IU/L) Presents in 1. Heart 2. Skeletal muscles 3. Liver 4. Kidneys 5. Brain 6. Malignant tissues LDH isoenzymes 1. LDH1:heart, erythrocytes, blast, kidneys 2. LDH2: heart 3. LDH3:intermediate 4. LDH4:liver 5. LDH5:liver Causes of serum LDH increase Marked increase 1. Myocardial infarction 2. Hematological diseases - Leukemia - Shock - Pernicious anemia Moderate increase 1. Viral hepatitis 2. Skeletal muscle diseases 3. Pulmonary embolism 4. Infections Artefacual increase Hemolysis of samples 3/20/2018 of Clinical Medical Biochemistry and 32

10 (5) Gamma Glutamyle transpeptidase (γ-gt) N= up to 38 U/L Presents in: 1. Liver 2. Kidneys 3. Pancreas Causes of GGT increase Liver diseases 1. Cirrhosis 2. Metastatic cancer 3. Hepatic infiltration 4. Cholestasis Chronic alcoholism Patient with anticonvulsant therapy 3/20/2018 of Clinical Medical Biochemistry and 33

11 3/20/2018 of Clinical Medical Biochemistry and 34

12 Major pathological changes in liver Liver cell damage Cholestasis Infiltration of liver Destruction of cell Impaired the secretion of bile Then accumulated in the plasma 1. Secondary to a disease 2. Abscess 3. Parasitic emboli As bilhariziasis cause destruction of cells Acute: as viral infection Chronic : Loss of function 3/20/2018 of Clinical Medical Biochemistry and 35

13 (1) Liver cell damage Causes: Viral infection Toxins (alcohol, paracetamol, acetaminophen) Hypoxia and congestion in chronic heart failure (CHF). Secondary to biliray obstruction. Biochemical effect: 1. Release of intracellular constituents into blood. 2. High sgot (AST) and sgpt(alt). - Massive destruction: sudden fall after high elevation - Chronic destruction: high level for long time ALT than AST Means liver viral hepatitis AST than ALT Means excess damage, cirrhosis, hypoxia and tumors 3/20/2018 of Clinical Medical Biochemistry and 36

14 Liver diseases and AST-to-ALT ratio Disease Ratio EtOH 1.5 Drugs 2.0 Cirrhosis Hepatocellular carcinoma (HCC) > 1.5 Intra hepatic cholestasis > 1.5 Extra hepatic cholestasis Acute viral hepatitis < /20/2018 of Clinical Medical Biochemistry and Acute myocardial infraction (MI) >

15 (2) Cholestasis With jaundice (Cholestatic jaundice) With out jaundice Extra hepatic Intra hepatic 1. Obstruction to only part of biliary system 2. Cholengitis 3. Primary biliary cirrhosis 1. Gall stones 2. Carcinoma (obstruction of bile duct) 1. Some forms of Viral hepatitis 2. Biliary cirrhosis 3. Drugs : phenothiazine. Biochemical changes 1. Plasma Bilirubin increased to be 50 mg/dl 2. ALP increases 3. ALT, AST increases 4. Increase GGT 5. Increase 5` nucleotidase 3/20/2018 of Clinical Medical Biochemistry and 38

16 (3) Liver infiltration CAUSES (1) Abscess (2) Amyloidosis (3) Tuberculosis (4) Parasitism Biochemical changes: (5) Carcinoma from lung or stomach High serum ALP High serum GGT Why? 1. Increase synthesis in sinusoids 2. Regarded to circulation 3. But it highest in Cholestasis Normal bilirubin ALT and AST normal or slight raised 3/20/2018 of Clinical Medical Biochemistry and 39

17 Case study (1): 0.41 mg/dl 17.1 µmol/l bilirubin=1 mg/dl 3/20/2018 of Clinical Medical Biochemistry and 40

18 Casestudy (1): 3/20/2018 of Clinical Medical Biochemistry and 41

19 Comments on case 1 1. Liver function tests indicate mild cell damage; this appeared from normal levels of AST and Bilirubin and slight increase of ALT (38/N = <35). 2. High serum ALP indicates one of the following: a) Bone metastasis tumor; and this not excluded by normal level of Ca as ALP is very high (bone scan is very important here) b) Metastatic breast carcinoma c) Hepatic metastatic carcinoma from breast 3. Further investigations are required a) Bone scan b) Tumor markers c) Histopathological examinations Aaser 3/20/2018 of Clinical Medical Biochemistry and 42

20 Hepatic coma Definition: is the occurrence of confusion, altered level of consciousness as a result of liver failure. Biochemical findings Abnormal liver function tests indicating liver failure High blood ammonia Serum ammonia levels are elevated in 90% of patients. Not all hyperammonemia (high ammonia levels) is associated with coma. 3/20/2018 Dr/ Aaser Abdelazim ----lecturer of Medical Biochemistry and 43

21 Causes: other causes with hepatic faliure may predispose coma like: Type Cause Excessive nitrogen load 1. Consumption of large amounts of protein 2. Gastrointestinal bleeding e.g. from esophageal varices (blood is high in protein, which is reabsorbed from the bowel), 3. Renal failure (inability to excrete nitrogen-containing waste products such as urea), 4. Constipation Electrolyte or metabolic disturbance 1. Hyponatraemia (low sodium level in the blood) and hypokalaemia (low potassium levels) these are both common in those taking diuretics, often used for the treatment of ascites 2. Alkalosis (decreased acid level), 3. Hypoxia (insufficient oxygen levels), 4. Dehydration Drugs and medications Infection Others 1. Sedatives: such as benzodiazepines (often used to suppress alcohol withdrawal or anxiety disorder), 2. Narcotics: (used as painkillers or drugs of abuse) and sedative antipsychotics, alcohol intoxication Pneumonia, urinary tract infection, spontaneous bacterial peritonitis, other infections Surgery, progression of the liver disease, additional cause for liver damage (e.g. alcoholic hepatitis, hepatitis A) Unknown 3/20/2018 In 20 30% of cases, no clear cause for an attack can be found Dr/ Aaser Abdelazim ----lecturer of Medical Biochemistry and 44

22 Hepatic failure (NH3) Ammonia (NH3) accumulates in the systemic circulation Crosses the blood-brain barrier Glutamate (NH3) Glutamine Increase the activity of GABA in brain due to conversion of α-ketoglutarate in to glutamate (inhibitory neurotransmitter) Excess Glutamine lead to increase the osmotic pressure in brain cells (become swollen) The energy to brain cells is decreased Due to depletion of α-ketoglutarate 3/20/2018 Brain edema (cytotoxic type) Dr/ Aaser Abdelazim ----lecturer of Medical Biochemistry and 45

23 1. Definition of jaundice 2. Bilirubin metabolism 3. Causes of jaundice 4. Differential diagnosis of jaundice 3/20/2018 of Clinical Medical Biochemistry and 46

24 1) Is a yellow discoloration of skin or/and sclera due to high concentration of plasma Bilirubin over 40 µmol/l 2) Normal plasma total bilirubin is less than 22 µmol/l (3-15 µmol/l OR mg/dl ) 3) Normal conjugated = 0.1 mg/dl 1. See bilirubin metabolism figure (3) 2. Main causes of high bilirubin are three figure (4) Hemolysis Failure of conjugation mechanism in liver Obstruction in biliary system 17.1 µmol/l bilirubin=1 mg/dl 3/20/2018 Jaundice of Clinical Medical Biochemistry and Indicates an elevated level of serum bilirubin. In neonates it is important to determine the concentration of Unconjugated bilirubin in order to decide the treatment required In adults most common type is due obstruction. 47

25 Non water soluble (not secreted from kidneys) It is neurotoxic Can cause permanent brain damage in neonates Water soluble Bacteria Figure (2) Bilirubin metabolism 3/20/2018 Orange color of urine on long standing of Clinical Medical Biochemistry and Brown coloration of feces If not present lead to pale colored feces 48

26 Figure (3): Causes of jaundice 3/20/2018 of Clinical Medical Biochemistry and 49

27 Hemolysis Extra hepatic obstruction Hepatocellular damage Complete Partial Plasma Unconjugated bilirubin Main in neonates >> 200 µmol/l (12 mg/dl); need phototherapy >> 300 µmol/l(17 mg/dl); need exchange transfusion 3/20/2018 Both Plasma bilirubin and ALP conjugated Little or no Stercobilinogen in intestine Little or no urobilinogen in urine Pale stool of Clinical Medical Biochemistry and Obstruction occurs here secondary to ALP with hepatic cell bilirubin within damage by toxins reference range or infection Level of ALP indicate the degree of obstruction Both Plasma bilirubin and ALP with ALT and AST Indicates damage of liver cells 50

28 Laboratory differential diagnosis of jaundice Feature Hemolytic Cholestatic Hepatocellular Serum Bilirubin >75 µmol/l (4.38 mg/dl) (Unconjugated) (Indirect) Over 3 times than in hemolytic (Conjugated) (Direct) >75 µmol/l but later (Unconjugated/conjugated) Conjugated increased when obstruction occurs later on Bilirubin in urine Not present (Unconjugated is not water soluble and bound to albumin and not filtered ) Present Present (high level of conjugated bilirubin) Urine Urobilinogen Increased Decreased /absent Decreased/absent Stool Normal Clay/pale in color (no bilirubin reaches the intestine) Normal Reticulocytosis Hemoglobin /Haptoglobin Decrease Normal Normal Plasma enzymes 3/20/2018 LDH may increased 1. ALP over 3 times the reference range it act as a mirror for the degree of obstruction. 2. High AST, ALT, GGT of Clinical Medical Biochemistry and LDH and High ALP but appear later High ALT and AST Due to hepatocytes damage 51

29 Neonatal jaundice Causes: 1. Inability of immature liver of neonates to produce UDPG- transferase 2. Higher turnover of neonatal erythrocytes shortly after birth to replace fetal HbF with normal HbA Neonatal jaundice Transient Sustained Physiological jaundice of the newborn (PJN) 1. Blood groups incompatibility between mother and fetus (+ direct antiglobulin) 2. Absorption of large 3/20/2018 hematoma. of Clinical Medical Biochemistry and 1. Hemolytic diseases 2. Biliray artesia (post hepatic type) 3. Idiopathic neonatal hepatitis (rare) (hepatic jaundice) 52

30 Mechanism of neonatal jaundice Group (O) or RH- Blood cells of mother Group (A/B) or Rh+ Blood cells of fetus Immune system of mother recognized them as foreigners Both come in contact 1. Through transfusion 2. Or during pregnancy Produce against them antibodies RBCs destruction Aaser 3/20/ High amounts of IgM (anti-a, anti-b) 2. Small amounts of IgG (anti-a, anti-b) of Clinical Medical Biochemistry and This usually not affects the 1 st child but affects the second one 53

31 Consequence of neonatal jaundice Treatment Kernicterus Phototherapy if the level exceed 10 mg/dl Brain cell nuclei stained yellow Source of light emitted light of 450 nm Unconjugated bilirubin (insoluble) Soluble bilirubin Damaged due to high bilirubin can cross blood brain barrier (not occurs in adults why?! Here type of bilirubin is unconjugated which is water insoluble). Usually brain is damaged if the level reaches > 20 mg/dl 3/20/2018 of Clinical Medical Biochemistry and cerebral palsy, deafness, mental retradation 54

32 Physiological jaundice of the newborn (PJN) Transient condition/ phenomena in which bilirubin subsides within few weeks 1. Increase total and Unconjugated bilirubin 2. Near-normal conjugated bilirubin 3. Normal hepatic enzymes if there is no iflammation Other factors affecting neonatal hyperbilirubinemia 1. Decrease binding of Unconjugated bilirubin to albumin 2. reabsorption of intestinal meconium 3. constituents in mother s milk. Progesterone and other hormones in breast milk as well as beta-glucuronidase may suppress neonatal conjugation of bilirubin 3/20/2018 of Clinical Medical Biochemistry and 55

33 Case study (2): 3/20/2018 of Clinical Medical Biochemistry and 56

34 Case study (2): 3/20/2018 of Clinical Medical Biochemistry and 57

35 3/20/2018 of Clinical Medical Biochemistry and 58

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