LIVER FUNCTION

• Liver
o Anatomy of the Liver
▪ Largest visceral and the most versatile organ in the body.
• Liver is capable of regeneration, but if damage is repeated over time the changes
would be irreversible.
• Death may occur in 24 hours if liver is nonfunctional
▪ Has two main lobes, separated from each other by falciform ligament right lobe is six
times larger than the left lobe.
▪ 1.2 – 1.5 kg in weight
▪ The Liver is composed of 2 cells:
• Hepatocytes – regenerative capacity of the liver, accounts for 80% of the livers total
volume
• Kupffer cells – acts as the macrophage present in the liver
▪ The cells are arranged into lobule, the anatomic unit of the liver.
• Lobules consist of 3 parts
o Hepatic Artery
o Portal Vein
o Bile Duct
▪ It receives 1500 mL of blood per minute which makes it extremely vascular, and blood is
supplied from two sources:
• Hepatic Artery
o 25% of total blood supply in the liver.
o Provides oxygen-rich blood
• Portal Vein
o 75% of total blood supply in the liver.
o Nutrient-rich blood
▪ Blood that is collected as food is digested
▪ Hepatic artery and portal vein merges to form central vein, which is the vein in which blood
leaves the liver in.
o Functions:
FUNCTION EXAMPLES
Synthesis Proteins – albumin (to maintain
oncotic pressure, most abundant
Almost all proteins are synthesized by serum protein)
the liver EXCEPT immunoglobulins
(produced by plasma cells) adult - Cholinesterase
hemoglobin (produced by bone
marrow) Coagulation proteins

Almost all coagulation proteins are Cholesterol

synthesized by the liver EXCEPT
Von-Willebrand Factor (produced by
the megakaryocytes and by the
endothelial cells)
Metabolism
Bile salts
Glycogen
Glucose exposed to pyruvate turns
into acetyl CoA a precursor from
different metabolic pathways

Glycogenesis
Glycogenolysis
Gluconeogenesis – conversion of
glucose from noncarbohydrate
sources (Amino acids, Fatty acids,
ketones)

Amino acid conversion

 Fatty acids
Detoxification Bilirubin ammonia

Drugs
Excretion Bile Acids

Board question:
Which of the following is a synthetic function of the liver? Answer: ALBUMIN
Which of the liver function tests are abnormal in cases of liver disorders? Answer: PT and PTT

o Tests for Liver Function

▪ Proteins
▪ Bilirubin
▪ Ammonia
▪ Enzymes (AST, ALT, GGT, ALP)
• Bilirubin
o It is the end product of hemoglobin metabolism and the principal pigment in bile
o It is formed from destruction of heme-containing proteins such as myoglobin, catalase, and
cytochrome oxidase.
o Characteristics of Bilirubin
▪ Orange yellow pigment derived from hemoglobin degradation.
▪ Extracted and bio-transformed mainly in the liver and is excreted in bile and urine
▪ Mainly transported by albumin

Bilirubin Metabolism
 RBC – 120/126 DAYS

Once RBCs have run their course

in the body, old senescent RBCs Hg – transported to
go to the spleen and are lysed, plasma by Haptoglobin
wherein they release hemoglobin. When haptoglobin
can no longer
Heme Globin transport Hg, Hg is
converted into
Heme and Globin
Hemopexin

When hemopexin can no

Iron Protoporphyrin longer transport Heme,
Heme is converted into
Iron and Protoporphyrin
Transferrin Biliverdin

New RBCs Bone Marrow Bilirubin

- Water Insoluble
- Non-Polar – has capacity to
LEGEND B1 (Unconjugated Bilirubin) accumulate in tissues which
- Being transported by/to can cause kernicterus
- Additional info - (UV oxidizes B1)
- Converted to Transported by albumin to - Indirect Bilirubin
LIVER (Site of conjugation)

Ligandin fetches B1 to be brought to the Rough

Endoplasmic Reticulum of Hepatocyte

Rough Endoplasmic Reticulum

UDPGT (Uridine diphosphate

glucuronosyltransferase/glucoronyltransferase) will
transfer 2 glucuronic acid molecules to Unconjugated
bilirubin to make it into Conjugated Bilirubin

- B2, Direct Bilirubin

● Directly reacts with diazo Conjugated Bilirubin
reagent
- Water Soluble and Polar
- Bilirubin Diglucuronide Biliary Tree
(contains 2 glucuronic acids)
- Can be excreted from body
Small Intestine
Urobilinogen – colorless
The excess 20% can go product, majority of which
back to the liver via the Normal flora of small intestine will reduce is secreted in the feces
extrahepatic circulation to direct bilirubin into mesobilirubin then into specifically 80% (50–250
be excreted again through mesobilirubinogen, then further to mg/day) in the form of
the feces or can enter the urobilinogen urobilin/stercobilin which
systemic circulation via the gives stool its brown color
portal vein to the blood to
be filtered by the kidneys
then excreted in the urine
 ▪ Two major forms:
B1 B2
Unconjugated Bilirubin Conjugated Bilirubin
Non-polar Bilirubin Polar Bilirubin
Water Insoluble Water Soluble
Indirect Bilirubin Direct Bilirubin
Hemobilirubin Cholebilirubin
Pre-Hepatic Bilirubin Post-Hepatic bilirubin / Hepatic Bilirubin /
Obstructive and Regurgitative Bilirubin

o Clinical Conditions Associated with Bilirubin

▪ Jaundice – yellowish discoloration of the skin and the sclera of the eyes
• Comes from the French word “jaune” which means YELLOW
• Jaundice will only be apparent if levels of bilirubin exceed by 5.0 mg/dL, but if levels
of bilirubin are at 1.5 to 3.0 mg/dL is called Overt Jaundice (High levels of bilirubin,
but skin is not yellow)
• Jaundice may be classified according to the onset of disease (Pre-Hepatic, Hepatic,
or Post-Hepatic)
o Pre-Hepatic
▪ The problem is before the liver
▪ Unconjugated Hyperbilirubinemia
▪ Hemolytic Anemia
o Hepatic
▪ Problem is the Liver
▪ There could be an intrinsic defect
▪ Gilbert’s Syndrome
• Impaired hepatic intake of Bilirubin
• Mutations on the UGT1A1
o UGT1A1 – responsible for secretion of UDPGT
• Patients with this disease exhibit unconjugated hyperbilirubinemia
• Low mortality rate
▪ Crigler-Najjar Syndrome
• Deficiency on enzyme of UDPGT causing high levels of
unconjugated bilirubin
• Type 1
o Complete Deficiency of UDPGT
• Type 2
o Partial Deficiency of UDPGT
▪ Dubin-Johnson Syndrome
• Problems with conjugated bilirubin
• Problem cMOAT (Canlicular Multi-specific Organic Anionic
Transporter Protein) / MDR2 (Multi Drug Resistant Transport Protein
Type 2) where in it cannot transport conjugated bilirubin
• Dark pigmentation of the liver and associated gallbladder defects
▪ Rotor Syndrome
• High levels of conjugated bilirubin
• Causes are unknown
• Though hypothesized to have a problem with Ligandin
• No dark pigmentation and no gallbladder defects

When conjugated bilirubin cannot be released it will noncovalently attach to albumin to create delta
bilirubin which can also act as direct bilirubin when tested will cause falsely increased levels

▪ Lucy-Driscoll Syndrome
• Autoimmune disorder that is characterized by the presence of
autoantibodies directed against UDPGT causing high levels of
unconjugated bilirubin
▪ Physiologic Jaundice of the Newborn
 • The last liver function that develops among newborns is the
production of UDPGT
• B1 (Unconjugated Bilirubin)
o Trans Form – less water soluble
o Cis Form – more water soluble upon oxidation of UV
o Post-Hepatic
▪ After bilirubin exits the liver
▪ Bile duct obstruction
• Pale colored stool because conjugated bilirubin cannot enter your
small intestine therefore no production of stercobilin which gives the
stool its brown color
▪ Kernicterus – deposition of bilirubin in the brain
▪ Cirrhosis – occurs when scar tissues replace healthy, normal liver tissues
▪ Biliary obstruction/ Bile duct obstruction
o Biliary atresia – failure of the common bile duct to form an opening
o Cholecystitis – inflammation of the gallbladder
o Cholelithiasis – gall stones, common among women
o Choledocholithiasis – presence of gall stones in the biliary tree
o Classification of Jaundice/ Hyperbilirubinemia
1. Pre-hepatic Jaundice
- Results when excessive amount of bilirubin is presented to the liver for metabolism or any
process of excessive erythrocyte destruction.
- Elevated indirect/unconjugated bilirubin
2. Hepatic Jaundice
- May result from impaired cellular uptake, defective conjugation, or abnormal secretion of
bilirubin by the liver cell.
- Gilbert Syndrome
• Is characterized by impaired cellular intake of bilirubin
• It is diagnosed in young adults (20-30 years old)
• Affected individuals may have no symptoms but may have mild icterus.
• Laboratory result: elevated B1/conjugated bilirubin (<3 mg/dL)
- Crigler-Najjar Syndrome
• Congenital hyperbilirubinemia caused by deficiency of UDPGT enzyme.
• Infants are treated by means of phototherapy
• Type I – complete deficiency of the enzyme UDPGT; total absence of B2
production; (+) kernicterus; bile is colorless
• Type II – it is characterized by partial deficiency of UDPGT; small amount of B2 is
produced.
- Lucy-Driscoll Syndrome
• A familial form of unconjugated hyperbilirubinemia caused by circulating inhibitor of
bilirubin conjugation
- Hepatocellular injury caused by virus, alcohol and parasites
- Autoimmune disorder that is characterized by the presence of autoantibodies directed
against UDPGT causing high levels of unconjugated bilirubin
- Dubin-Johnson Syndrome
• Characterized by deficiency of multi specific organic anionic transporter protein
(MDR2/cMOAT).
• Removal of conjugated bilirubin from the liver cell and the excretion into the bile are
defective.
• Appearance of dark-stained granules on a liver biopsy sample
- Rotor Syndrome
• Clinically similar with Dubin-Johnson but the defect is not known. There is a
possibility that it is due to a reduction in the concentration or activity of intracellular
binding protein such as ligandin.
• Liver biopsy does not show dark pigmented granules
3. Post Hepatic Jaundice
- Impaired bilirubin excretion caused by mechanical obstruction of the flow of bile into the
intestine which may be due to:
 • Intrahepatic cholestasis – may occur because of inflammation or swelling of liver cells
which then blocks excretory ducts in the liver causing defective transport of B2 into
the bile canaliculi

Pre-hepatic vs Hepatic vs Post Hepatic Hyperbilirubinemia

Serum B1 Serum B2 Urine Bilirubin Urine Color of Stool
Urobilinogen
Prehepatic Increased Normal Negative Increased Dark brown
Stool
Hepatic Increased Increased Positive Increased ---
Post hepatic Normal Increased Positive Decreased / Clay-colored
Normal stool

o Specimen Consideration and Patient Preparation

- Fasting serum specimen
• Lipemia may cause falsely increased levels
- Non-hemolyzed specimen, hemolysis causes false results
• Hemolysis may cause falsely DECREASED result (e.g., bilirubin, uric acid, lipase)
- Serum is preferred to minimize turbidity produced by plasma proteins
- Sample must be protected from direct exposure to light because bilirubin is
photosensitive and breaks down upon exposure to light.
- Sample should be measured 2-3 hours after collection.
- It is stable for 2 days at room temperature, 1 week at 4 C and indefinitely at -20 C.
o VI. Methodologies
- Ehrlich Reaction
• Diazotized sulfanilic acid for bilirubin used in urine
- Van den Bergh Reaction
• Basis for modern bilirubin determination
• Diazotized sulfanilic acid for bilirubin used in serum
• Diazotized sulfanilic acid is formed by reacting sulfanilic acid with sodium nitrite and
hydrochloric acid

Assay Evelyn-Malloy Jendrassik-Grof

pH Acid Alkaline (normally carried at an
acidic pH)
Dissociating Agent 50% Methanol Caffeine-sodium benzoate
Diazo Product Red or reddish-purple color Blue (maximum absorbance
(absorption maximum in the around 600 nm)
region of 560 nm)
An addition of the alkaline tartrate solution would shift the pH in the Jendrassik-Grof method to be basic
Ascorbic acid in Jendrassik-Grof terminates the reaction by destroying the excess diazo reagent
Azobilirubin – product that is being measured
- Direct Spectrophotometric Method
• Absorbance of bilirubin in serum at 455 nm is proportional to the concentration;
absorbance of hemoglobin at 455 nm can be corrected by subtracting absorbance at
575 nm.
- Icterus Index
• Subjective; test involves diluting serum with saline until it visually matches the color of
a 0.1% potassium dichromate solution; interference with carotene, xanthrophyll, and
hemoglobin may occur due to presence of color.
• Qualitative test
o Values to Remember
- Reference Values
• Total bilirubin: 0.2 to 1.0 mg/Dl
• Direct bilirubin: 0 to 0.2 mg/dL
• Indirect bilirubin: 0.2 to 0.8 mg/dL
- Conversion Factor of bilirubin: mg/dL to µmol/L = 17.1
- Critical value for bilirubin > 18 mg/dL