LIVER FUNCTION TESTS

Functions of Liver:

 Synthetic Function
 Metabolic Function
 Detoxification Function
 Homeostasis
 Excretion
 Storage Function
 Production of bile salts.

Indications of Liver Function Tests:

1) Jaundice

2) Suspected liver metastasis

3) Alcoholism

4) Any undiagnosed chronic illness

5) Annual check-up of diabetic patients

Classification of LFT's

Group I (Tests for hepatic excretory function)

(i) Serum Bilirubin - Total, conjugated and unconjugated.

(ⅱ) Urine pigments, bile salts and urobilinogen

Group II Liver Enzyme Panel

Alanine Aminotransferase (ALT)

Aspartate Aminotransferase (AST)

Alkaline Phosphate (ALP)

Gamma glutamyl transferase (GGT)

Group III Tests for synthetic function Marker for chronic liver diseases function

i. Total proteins
ii. Serum albumins globulins A/G ratio
iii. Prothrombin

Group Ⅳ Special Test (Tests for metabolic liver diseases)

i. Ceruloplasmin
 ii. Ferritin and iron
iii. Alpha Antitrypsin (AAT)
iv. beta-2 microglobulin (b2m)
v. Alpha fetoprotein (AFP)

Group V Direct and indirect markers of hepatic fibrosis

i. Serum hyaluronic acid (SHA)

ii. Procollagen type I carboxy terminal peptide (PICP)
iii. Procollagen type Ⅲ amino terminal peptide (PINP)
iv. Matrix metalloproteinase (MMPs)
v. Tissue inhibition of MMPs (TIMPs)
vi. Transforming growth factor beta 1 (TGFB-1)

CLASSIFICATION BASED ON CLINICAL ASPECTS

Group I- Markers for Liver dysfunction

(i) Serum – Bilirubin, total unconjugated, conjugated

(ii) Urine - Bile pigments, Bile salts and UBG

(iv) Prothrombin time

(i) Total protein, serum albumin and A/G ratio

(v) Blood ammonia, when indicated.

Group II- Markers for hepatocellular injury

1. Alanine Aminotransferase (ALT)

2. Aspartate Aminotransferase (AST)

Group III- Markers for cholestasis

1. Alkaline phosphatase
2. Gamma glutamyl transferase

Hemolytic jaundice Obstructive jaundice Hepatocellular

jaundice
Total bilirubin elevated elevated elevated
Conjugated bilirubin normal elevated elevated
Unconjugated elevated normal elevated
bilirubin
Vandenbergh test Indirect +ve Direct +ve biphasic
Measurement of Bilirubin

 Bilirubin is estimated by Vandenbergh reaction, where diazotised sulfanilic acid (in HCl
and NaNO3 ) reacts with bilirubin to form a complex azobilirubin.
 Normal serum bilirubin level varies from 0.2-0.8 mg/dl
 The unconjugated bilirubin varies from 0.2 to 0.7 mg/dl and conjugated bilirubin 0.1 to
0.4 mg/dl.
 When bilirubin is conjugated, the purple colour is produced mixing with the reagent, the
response is said to be vandenberg Direct +Ve.
 When bilirubin is unconjugated, the colour is obtained only when alcohol is added and
this is known as Indirect +ve
 If both conjugated and unconjugated bilirubin are present in increased amounts, a purple
colour is produced immediately which is intensified on adding alcohol is called biphasic.

In Hemolytic Jaundice, Unconjugated bilirubin is increased Vandenberg test - Indirect positive.

In obstructive test, conjugated bilirubin is increased Vandenberg test - Direct positive.

In Hepatocellular Jaundice a biphasic reaction is observed because both conjugated and

unconjugated bilirubins are observed.

Measurement of urinary bilirubin:

In all cases of Jaundice, urine should be examined for the presence of bile pigments, bile salts &
urobilinogen only conjugated bilirubin is soluble in water and is excreted in urine

Hence in prehepatic jaundice, when the unconjugated bilirubin is increased in blood, it does not
appear in urine, hence called alcoholic jaundice.

Urinary Urobilinogen

In cases of obstruction, bile is not reaching the intestine and so urobilinogen may be decreased
(or) absent.

In hepatocellular jaundice, urobilinogen is initially elevated, then decreases (or) disappears

when the obstructive stage sets in and reappears when obstruction is cleared.

Urobilinogen is absent in urine, when there is obstruction to bile flow.

The first indication of recovery is the reappearance of urobilinogen in urine.

In hemolytic anemias, urobilinogen is increased.

Bilirubin detected by Fouchet's test and Urobilinogen by Ehrlich's test

Urine Bile salts:

Normally bile salts (sodium of taurocholic and glycocholic acid) are present in bile duct not in
urine.

Bile salts in urine are detected by Hay's test.

Positive Hay's test indicates the obstruction in the biliary passages causing regurgitation of bile
salts into systematic circulation leading to its excretion in urine.

Specimen Test Prehepatic Hepatocellular Post hepatic

jaundice Jaundice jaundice
Urine Bile salt (Hay’s Absent Absent Present
Test)
Urine Conjugated Absent Present Present
bilirubin
(Fouchet’s)
Urine Urobilinogen +++ Increased in Absent
(Ehrlich’s Test) early phases,
later decreased
Feces Urobilins ++ Normal (or) Clay colored
decreased

Test for Serum Albumin:

• All plasma proteins except immunoglobulins are synthesised by the liver.

• Serum albumin is quantitatively the most important protein synthesized by the liver and reflects
the extent of functioning liver cell mass.

• Normal albumin level in blood is 3.5 to 5g /dl and globulin level is 2.5 to 3.5 g/dl.

Others tests based on Synthetic function-

(i) Prothrombin Time (PT)

(ii) Alpha-fetoprotein (AFP)

(iii) Ceruloplasmin (CP)

(iv) Transthyretin (Pre-albumin)

(v) α-1antitrypsin (AAT)

(vi) Haptoglobulin

Test Based on Serum Enzymes

The enzymes used in the assessment of hepatobiliary disease may be divided into two groups:

(a) Those indicating hepatocellular damage.

(b) Those indicating cholestasis (obstruction).

Clinical Significance

Normal AST ALT ratio is 0.8. A ratio >2 is seen in

 Alcoholic hepatitis
 Hepatitis with cirrhosis
 Nonalcoholic Steatohepatosis (NASH)
 Liver metastasis
 Myocardial infraction
 Erythromycin

ALT higher than AST is seen in:

 Acute hepatocellular injury

 Toxic exposure
 Extra hepatic obstruction cholestasis

Markers of obstructive Jaundice -

1. Alkaline phosphate (ALP)

 Very high values of ALP are noticed in patients with cholestasis or hepatic carcinoma.
 Bile duct obstruction includes the synthesis of the enzyme by biliary tract epithelial cells.
 In parenchymal diseases of the liver, mild elevation of ALP is noticed.
 In hepatitis, inflammatory edema produces an obstructive phase, during which ALP level
is elevated.
 Very high levels of ALP (10-12times) may be noticed in extra hepatic obstruction caused
by gallstones (or) carcinoma of head of pancreas.
 Intrahepatic obstruction causes consequent irritation cholestasis may be due to virus
(infective hepatitis) (or) by drugs (chlorpromazine)
 Drastically high levels of ALP (10-25) times are seen in bone diseases where osteoblastic
activity is enhanced like:
a. Pagets disease
b. Rickets
c. Osteoblastoma
d. Osteomalacia
e. Metastatic carcinoma of bone and Hyperparathyrodism.

Enzymes Indicating Hepatocellular Damage-

• Normal Serum ALT is 10-35 IU/L

• The levels of aminotransferase (ALT and AST) in serum are elevated in all liver diseases.

• Very high levels (more than 1000 units) are seen in acute hepatitis (viral and toxic)

• The degree of elevation may reflect the extent of hepatocellular necrosis.

Gamma Glutamyl Transferase-

  Alcohol Abuse.
 GGT level in alcoholic liver disease is roughly parallel to the alcohol intake.
 Elevated levels of GGT are seen in chronic alcoholism, pancreatic disease, myocardial
infarction, Renal failure, chronic obstructive pulmonary disease
 In liver disease, GGT elevation parallels that of ALP and is very sensitive of biliary tract
disease.

Clinical Manifestations of Liver dysfunction

 Jaundice
 Portal Hypertension
 Pre-sinusoidal Ex: Portal vein thromobosis
 Sinusoidal Ex: cirrhosis
 Post sinusoidal Ex. Hepatic vein thrombosis
 Ascites

Clinical Manifestations of Liver Failure:

Liver:

 Loss of metabolic function.

 Decreased gluconeogenesis leading to hypoglycemia. Decreased lactate clearance leading
to hyper lactic Acidosis
 Decreased ammonia clearance leading to hyperammonemia
 Decreased synthetic capacity leading to coagulopathy.
 Portal hypertension.

Lungs:

 Adult Respiratory Distress syndrome.

Adrenal Glands

 Inadequate glucocorticoid production contributing to hypertension.

Brain

 Hepatic encephalopathy
 Cerebral edema
 Intracranial hypertension.

Causes of Hepatocellular Damage-

1. Viruses - HAV, HBV, HCV, Herpes, Adenoviruses

2. Alcohol

3. Toxins:- CCl4, Chloroform, Mushroom-Aflatonin, Arsenic

4. Immunological- Autoimmune hepatitis, NASH.

5.General diseases- Wilson's disease, hemochromatosis, AAT deficiency, porphyrias,
sacroidosis, Amyloidosis.

6. Neoplasm & Hepatocellular disease, lymphoma. carcinomas, metastatic liver diseases.

7. Bacterial infection - TB, leptospirosis, Brucella, Abcesses.

8. Parasites - Helminthes, Amoebiasis, Plasmodia, Leishmania

9. Drugs - Salicylate, Tetracyclines, Methotrexate, Isoniazid, Rifampicin, Halothene,

Methyldopa, Valproate.