Liver Function tests

Why function tests?

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Objectives

• The liver and its functions

• Common causes of Liver dysfunction

• Diagnosis of liver disease using clinical

chemistry

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Blood Supply to the liver ?

• Three sources of blood

• Hepatic artery (oxygenated blood)

• Hepatic vein (deoxygenated blood, waste)

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More on blood vessels in the liver
• The blood vessels terminates in sinusoids
(capillary-like vessels)

• The sinusoids merge with the blood of the

hepatic vein.

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http://biology.about.com/library/organs/bldigestliver.htm

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The liver under the microscope:

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 a lobule is a roughly hexagonal arrangement of plates of hepatocytes radiating
outward from a central vein. Central veins are quite prominent and provide an easy
means of orientation in sections of liver.

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 Zones of the liver

• The liver can be divided into zones for functional and

anatomical reasons

• zone 1,
• peri-portal-triad zone,
• zone 2,
• intermediate zone, damaged in yellow
fever
• zone 3,
• peri-central vein zone, get least blood
supply, fatty changes and most
susceptible to ischemic damage.
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What does the liver do?

• The liver is highly efficient at receiving

materials to be used or processed

• General Metabolism
• Anabolism
• Catabolism

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 Catabolism of hormones Glucose homeostasis;
and other serum proteins glycogenolysis & gluconeogenesis

Chronic Liver
Disease
Synthesis:
- Albumin
- Coagulation factors
Storage:
Bile excretion - Glycogen
- Iron
- Cu, Iron, vitamins

Katharine Brown 18
 Enterohepatic circulation
• A recycling process where bile acids are
absorbed in the intestine and secreted by
the liver

Liver
Cholesterol Cholesterol
Bile acids Bile acids
(Primary) (secondary)

Intestine
Faeces

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During Liver disease/damage

• loss of function
• Release cell constituents
• Inflammation
• Release of intracellular enzymes
• Necrosis and /or Apoptosis (cell death),

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Other relevant properties
• Unique ability to regenerate;

• Growing back after surgical removal of a

large portion (approximately 80%)

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Common causes of Liver dysfunction

• Liver Disease

• Pre-hepatic

• Intra-hepatic

• Post-hepatic

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Biochemical Tests of Liver Function

• What do you look for ?

• Blood components

• How?

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• Main categories:

• Bilirubin

• Plasma enzymes

• Plasma Proteins

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Bilirubin
• Disorders of Bile Pigment Metabolism

• Total serum bilirubin: 2 to 20 mol/L

• Esterified bilirubin: 0.3 - 5.0 mol/L

• >40mol/L Jaundice (yellowish pigmentation)

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What causes increased bilirubin?
(Hyperbilirubinaemia)
• Non-hepatic (pre-hepatic)

• Intra-hepatic

• Post-hepatic

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 WHERE DOES BILIRUBIN COME FROM?

red blood cells

120 days (senescence)

R-E system (phagocytosis, digestion)

spleen,
liver
bone marrow
haemoglobin bilirubin
(6g/day)

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• Catabolism of Haemoglobin and the
formation of bile pigments (bilirubin)

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RBC R-E system

Globin
HAEMOGLOBIN Iron Ferritin

Amino acids

Bilirubin albumin

Blood (albumin)

bilirubin-albumin Hepatocyte
membrane
ligandin

Rough ER
*
Bilirubin glucoronide
Bile glucuronidation

* Uridyl diphosphate
glucuronyl(UDPG)
Transferase
liver

bacteria 32
In t e s t in e u r o b ilin o g e n Fa e c e s
Non-hepatic (pre-hepatic)

Haemolysis

excessive Bilirubin load

excessive urobilinogen
faecal urobilinogen
urobilin

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Haemolytic Disease of the New-born (HDN)

• Isoimmune Haemolytic Disease(IHD).

• Caused by blood (antigen) incompatibility

(mother and foetus)

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blood incompatibility (mother and
foetus)

Previous maternal sensitisation to

foetal blood antigens

Activated complement binds to the

attached IgG and destroys the red
cells (lytic enzymes).

The haemolytic process may

continue for several weeks after
birth

s e ve re ja u n d ice re s u lt s

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 severe jaundice results

Saturation of plasma binding sites

release of bilirubin in the brain,

Brain damage (Nuclear

staining;kernicterus) mental retardation
340 mol/L

brain damage in new-borns

(d e p e n d in g o n p la s m a a lb u m in )

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Other factors which increase plasma
bilirubin
Liver malfunction

• Gilbert's syndrome

• A congenital malfunction of Uridyl diphosphate

glucuronyltransferase (UDPGT)

• Less enzymes is produced

• Defective Transport of bilirubin into the Hepatocyte

• Ligandin 37
• Children with defective UDPG
Transferase caused by a mutation
• (Crigler-Najjar syndrome)

• Physiologic Jaundice (Newborn Low

levels of UDPG transferase)

• Physiological jaundice usually

• peaks 48-72 hours
• disappears by 1 week

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Factors Associated with Physiological
Jaundice
• Hb level is higher than required
• RBC have shorter life
• Hepatic Immaturity

• - reduced glucuronyl transferase activity

• - reduced active uptake of UB
• - reduced intracellular transport system
• - reduced active secretion of CB
• - large enterohepatic circulation of
bilirubin to add to the load of UB in the
hepatocyte

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Intrahepatic
• Liver disease or cell destruction

• common causes:

• Viral hepatitis
• Hepatitis produced by xenobiotics:
• drugs
• chemicals (phosphorus
• arsenic chlorinated solvents)

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• Intrahepatic cholestasis

• Urinary excretion of urobilinogen may be

increased

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Posthepatic

• extrahepatic cholestasis:

• Bile  intestine

• major cause of jaundice elevated serum

bilirubin (esterified and nonesterified)

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The liver produces bile which aids in the digestion of fats. The bile travels
through tiny canals which eventually drain through the common bile duct into
the small intestine. The gallbladder stores excess bile that is not immediately
needed for digestion. 43
Accumulation of bilirubin in the hepatocyte.

• Caused by:

• Gallstones (bile ducts or gallbladder)

• Inflammation

• Carcinoma (pancreatic)

• Other tumours (common bile duct)

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Cholestasis

obstruction in the biliary tree

bile

intestine

A major cause of jaundice

elevated serum bilirubin (esterified and non-

esterified)
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impairment of the excretory transport system

Accumulation of bilirubin in the hepatocyte.

esterified

Portal
into the bloodstream bilirubin
(h yp e rb iliru b in ae m ia ) u rib ilin og en

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• In post hepatic hyperbilirubinemia, 60% is esterified
bilirubin

• In early stages test are positive for bilirubin glucuronide

• Less bilirubin reaches the gut

• Fewer pigments in the faeces:

• pale yellow
• brown
• clay-coloured

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In complete cholestasis

Urinary urobilinogen 0

Failure to digest and absorb ingested fats

pale, fatty, bulky stools.

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Diagnosis of liver disease

• Biochemical Tests of Liver dysfunction

• Main categories:
• Bilirubin
• Plasma enzymes
• Plasma proteins

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What is detected?

• More bilirubin in serum

• more uribilinogen in circulation

• uribilinogen in the urine

• Hyperbilirubinaemia may result from elevated

conjugated or unconjugated bilirubin, you must
measure both.

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Uncojugated hyperbilirubinaemia

• Plasma levels rarely exceeds 100g/l

• Where there is no liver cell
damage/disease hyperbilirubinaemia is
associated with:
• Haemolysis
• (increased bilirubin production)
• Gilberts syndrome
• (abnormal metabolism)
• Similar signs in physiological jaundice and
related diseases
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Conjugated Hyperbilirubinaemia

• Due to leakage of bilirubin from:

• Hepatocytes

• Biliary system following blockage

• Conjugated bilirubin enters the circulation

and produces a deep orange-brown urine
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Plasma Enzymes

• A range of enzymes may be used

• Not specific for liver function

• (good for damage)

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Enzymes levels change with
progression of the disease
• Aminotransferase (Aspartate and Alanine)
• can increase 20 x ULN

• Alkaline Phosphatase (liver isoenzyme specific)

• can increase 10 x ULN

• mainly in cholestasis (induction and from biliary system)

• -glutamyltransferase

• sensitive but not specific for liver disease

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• Enzymes measurement are never enough

• What other tests could you do?

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Plasma proteins

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Examples of plasma proteins:

Albumin,

Clotting factors,

Haptoglobin

Transferrin,

Ceruloplasmin

Lipoproteins

-antitrypsin

-macroglobulin,

Immunoglobulins

The complement
system.
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• Albumin :
• A reflection of the functional activity
of the liver
• Normal levels in early stages of acute
disease
• The level decreases in chronic liver
disease

• Remember the functional reserve of the

liver

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 Separation
• Cellulose acetate electrophoresis

• Gels (agarose)

• five bands

• Albumin, 1, 2, , and 

• quantified by densitometry
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Figure 1.
The image on the left is pure serum.
The image on the seperation of serum into different categories
when the serum goes through electrophoresis

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• http://www.youtube.com/watch?v=z2D7Zk
T3aOo

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 Five groups on cellulose acetate or
agarose:

• Albumin (quantitatively the largest protein).

• 1-globulins (mainly 1-antitrypsin).

• 2-globulins (2-macroglobulin and

haptoglobin, immunoglobulins).

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• -globulins ( two types 1; transferrin &
LDL, 2 the C3 component of complement,
immunoglobulins).

• a fibrinogen band will be seen if plasma is

used.

• -globulins (immunoglobulins).
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The Electrophoresis pattern of
plasma proteins in disease

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Prothrombin time
Two factors to consider

• Clotting time is a reflection of the synthesis

vitamin-K dependent factors

• Factor VII very short half-life (5-hours)

• Clotting time is an indicator of acute liver

disease but can be confused with vitamin-
K deficiency

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Immunoglobulins

• Frequently increased in chronic liver disease

(auto-immune)
• Must measure total protein as albumin level will
decrease
• Elevated:
• IgA (alcoholic liver disease)
• IgG (autoimmune hepatitis)
• IgM (biliary cirrhosis)

• Best test are for autoantibodies (anti-

mitochondrial, anti-nuclear)

• Must test for viral antigens and antibodies.

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