Liver Function Tests

ALT and AST

ALT and AST are both a marker of hepatocyte damage and circulating hepatocyte enzymes - hepatocellular pattern Aspartate transaminase (AST) (normal: 0-31 U/L) Lesser amounts also found in skeletal muscle, brain, myocardium kidney Levels rise slowly after damage and clear quickly after damage ceases half life 12-24h Alanine transaminase (ALT) (normal: 0-31 U/L) Most LIVER specific Rises slowly after damage and clears gradually after damage ceases half life of 40-60h

Acronym for conditions causing hepatitis ABCDEFGHI

Autoimmune (via genetic predisposition or acute liver infection) Hep B Hep C (viral hepatitis) Drugs Ethanol Fatty liver disease (NASH/NAFLD) Growth tumours Haemodynamic factors heart failure Infiltrative haemachromatosis, wilsons disease (copper deposition)

Conditions and AST, ALT ratios

Alcoholic related hepatic injury (only about 10% of problem drinkers have elevated AST) AST > ALT generally in 2:1 ratio toASTed Also mild macrocytosis (MCV >100fl) in 30-60% Non-alcoholic steatohepatitis (NASH) aka non alcoholic fatty liver disease (NAFLD) ALT > AST Elevations within 3x UNL Hepatitis Hep ABCDE, drug induced hepatitis, industrial chemical (toxic) hepatitis ALT > AST Elevations of both > 10x UNL (upper normal limit) Acetaminophen toxicity Massive AST and ALT rise Both >20x UNL

ALP aka AP
Alkaline phosphatase (normal: 0-125 U/L) indicative for damage to the biliary tree Anywhere along the tree left and right hepatic duct, common hepatic duct, cystic duct, CBD cholestatic picture chole means bile and static means stasis Also found in bone, placenta and gut i.e rapidly dividing or metabolically active tissue. Increase in ALP may indicate damage OR accelerated cellular division in these areas

GGT
Gamma glutamyl transferase (normal: 0-45 U/L) If also raised with ALP, tells you that any present ALP is coming from the biliary tree if GGT negative then try to find another cause for the raised ALP Also found in the kidney

Conditions and ALP, GGT

PBC - Primary biliary cirrhosis (autoimmune) Pathology slow progressive destruction of small bile ducts of the liver build up of bile in the liver (cholestasis) tissue damage (scarring fibrosis cirrhosis) Look for deranged LFTs GGT, ALP. Also antibodies ANA, AMA PSC primary sclerosing cholangitis Cholelithiasis cholestasis Acute cholecystitis can lead to abscess and fistula Choledocholithiasis stone in the CBD Ascending cholangitis infection inside the biliary tree airising from microbes migrating upwards from the duodenum

Measuring Liver function PT via coagulation factors (makes all factors except factor VIII-vWF), albumin, bilirubin
Prothrombin time PT Reflective of whether the liver is still functioning Liver okay = still making I, II V, IX, X, XII Takes a while before PT is altered 80% of liver cells are already dead Albumin most ubiquitous protein produced by the liver and provides most of the oncotic pressure of the blood Bilirubin Degradation product of heme with 90% arising from haemoglobin and a smaller % from myoglobin Production 4mg/kg/day and usually matched by excretion levels remain low and stable High bilirubin can displace drugs that have a high propensity for albumin increase of free drug concentration