ALANINE AMINOTRANSFERASE

The alanine aminotransferase (ALT) test is used to measure serum levels of ALT, one of two enzymes that catalyze a reversible
amino group transfer reaction in the Krebs cycle. ALT is necessary for energy production in tissues. It’s found primarily in the
liver, with lesser amounts in the kidneys, heart, and skeletal muscles. ALT is a sensitive indicator of acute hepatocellular disease.

PURPOSE
◆ To detect acute hepatic disease, especially hepatitis and cirrhosis without jaundice, and evaluate its treatment
◆ To distinguish between myocardial and hepatic tissue damage (used with aspartate aminotransferase)
◆ To assess the hepatotoxicity of some drugs

PATIENT PREPARATION
◆ Explain to the patient that this test is used to assess liver function.
◆ Explain that the test requires a blood sample, and tell the patient when and where it will be taken.
◆ Inform the patient that he need not restrict food or fluids.

REFERENCE VALUES
Serum ALT levels range from 10 to 40 U/L (SI, 0.17 to 0.68 kat/L) in males and 7 to 35 U/L (SI, 0.12 to 0.60 kat/L) in females.

ABNORMAL FINDINGS
Very high ALT levels (up to 50 times normal) suggest viral or severe druginduced hepatitis or other hepatic disease with
extensive necrosis. Moderate to high levels may indicate infectious mononucleosis, chronic hepatitis, intrahepatic cholestasis or
cholecystitis, early or improving acute viral hepatitis, or severe hepatic congestion as a result of heart failure.

Slight to moderate elevations of ALT may appear in any condition that produces acute hepatocellular injury, such as active
cirrhosis and drug-induced or alcoholic hepatitis. Marginal elevations occasionally occur in acute myocardial infarction (MI),
reflecting secondary hepatic congestion or the release of small amounts of ALT from myocardial tissue.

ALDOSTERONE, SERUM

The aldosterone test measures serum aldosterone levels by quantitative analysis and radioimmunoassay. Aldosterone regulates
ion transport across cell membranes to promote reabsorption of sodium and chloride in exchange for potassium and hydrogen
ions. Consequently, it helps to maintain blood pressure and volume and regulate fluid and electrolyte balance. This test identifies
aldosteronism and, when supported by plasma renin levels, distinguishes between the primary and secondary forms of this
disorder.

PURPOSE
◆ To aid in the diagnosis of primary and secondary aldosteronism, adrenal hyperplasia, hypoaldosteronism, and salt-losing
syndrome

PATIENT PREPARATION
◆ Explain to the patient that this test helps determine if symptoms are caused by improper hormonal secretion.
◆ Explain that the test requires a blood sample, and tell the patient when and where it will be taken.
◆ Instruct him to maintain a lowcarbohydrate, normal-sodium diet (135 mEq or 3 g/day) for at least 2 weeks or, preferably, for
30 days before the test.
◆ Withhold all drugs that alter fluid, sodium, and potassium balance — especially diuretics, antihypertensives, steroids,
hormonal contraceptives, and estrogens — for at least 2 weeks or, preferably, for 30 days before the test, as ordered.
◆ Withhold all renin inhibitors for 1 week before the test, as ordered. If they must be continued, note this information on the
laboratory request. ◆ Tell the patient to avoid licorice for at least 2 weeks before the test because it produces an aldosterone-like
effect.

REFERENCE VALUES
Laboratory values vary with the time of day and with the patient’s posture— values are higher when patients are in an upright
position. In upright individuals, a normal value is 7 to 30 ng/dl (SI, 0.19 to 0.83 nmol/L). In supine individuals, values are 3 to 16
ng/dl (SI, 0.08 to 0.44 nmol/L).

ABNORMAL FINDINGS
Excessive aldosterone secretion may indicate a primary or secondary disease. Primary aldosteronism (Conn’s syndrome) may
result from adrenocortical adenoma or carcinoma or from bilateral adrenal hyperplasia. Secondary aldosteronism can result from
renovascular hypertension, heart failure, cirrhosis of the liver, nephrotic syndrome, idiopathic cyclic edema, and the third
trimester of pregnancy. Low serum aldosterone levels may indicate primary hypoaldosteronism, salt-losing syndrome, eclampsia,
or Addison’s disease.
 ALKALINE PHOSPHATASE

The alkaline phosphatase (ALP) test is used to measure serum levels of ALP, an enzyme that affects bone calcification as well as
lipid and metabolite transport. ALP measurements reflect the combined activity of several ALP isoenzymes that are found in the
liver, bones, kidneys, intestinal lining, and placenta. Bone and liver ALP is always present in adult serum, with liver ALP the
most prominent except during the third trimester of pregnancy, when about half of all ALP originates in the placenta. The
intestinal variant of ALP can be a normal component (found in less than 10% of normal patterns and almost exclusively in the
sera of patients with blood groups B and O), or it can be an abnormal finding associated with hepatic disease.

PURPOSE
◆ To detect and identify skeletal diseases that are primarily characterized by marked osteoblastic activity
◆ To detect focal hepatic lesions that cause biliary obstruction, such as a tumor or abscess
◆ To assess the patient’s response to vitamin D in the treatment of rickets
◆ To supplement information from other liver function studies and GI enzyme tests

PATIENT PREPARATION
◆ Explain to the patient that this test is used to assess liver and bone function.
◆ Instruct the patient to fast for at least 8 hours before the test because fat intake stimulates intestinal secretion of ALP.
◆ Explain that this test requires a blood sample, and tell the patient when and where it will be taken.

REFERENCE VALUES
Total ALP levels normally range from 25 to 100 U/L (SI, 0.43 to 1.70 mkat/L) in females older than 15 years and males older
than 20 years.

ABNORMAL FINDINGS
Although significant elevations may occur with diseases that affect many Amylase, serum 149 organs, an elevated ALP level
usually indicates skeletal disease or extrahepatic or intrahepatic biliary obstruction causing cholestasis. Many acute hepatic
diseases cause elevated ALP levels before they affect serum bilirubin levels.
Moderate increases in ALP levels may reflect acute biliary obstruction as a result of hepatocellular inflammation in
active cirrhosis, mononucleosis, and viral hepatitis. Moderate increases also occur in osteomalacia and deficiencyinduced rickets.
Sharp elevations in ALP levels may indicate complete biliary obstruction by malignant or infectious infiltrations or
fibrosis. These are most common in Paget’s disease and occasionally occur in biliary obstruction, extensive bone metastasis, and
hyperparathyroidism. Metastatic bone tumors caused by pancreatic cancer increase ALP levels without a concomitant rise in
serum ALT levels.
Isoenzyme fractionation and additional enzyme tests (gamma glutamyl transferase, lactate dehydrogenase [LD], 5-
nucleotidase, and leucine aminopeptidase) are sometimes performed when the cause of ALP elevation is in doubt. Rarely, low
levels of serum ALP are associated with hypophosphatasia and protein or magnesium deficiency.

AMYLASE, SERUM
An enzyme that’s synthesized primarily in the pancreas and salivary glands, amylase (alpha-amylase, or AML) helps to digest
starch and glycogen in the mouth, stomach, and intestine. In cases of suspected acute pancreatic disease, measurement of serum
or urinary AML is the most important laboratory test.

PURPOSE
◆ To diagnose acute pancreatitis
◆ To distinguish between acute pancreatitis and other causes of abdominal pain that require immediate surgery
◆ To evaluate possible pancreatic injury caused by abdominal trauma or surgery

PATIENT PREPARATION
◆ Explain to the patient that this test is used to assess pancreatic function.
◆ Inform the patient that he need not fast before the test but must abstain from alcohol.
◆ Explain that this test requires a blood sample, and tell the patient when and where it will be taken.
Reference values
Normal serum AML levels range from 25 to 125 U/L (SI, 0.4 to 2.1 kat/L) for adults age 18 and older.

ABNORMAL FINDINGS
After the onset of acute pancreatitis, AML levels begin to rise within 2 hours, peak within 12 to 48 hours, and return to
normal within 3 to 4 days. Urine levels of AML should be measured after normal serum AML results are obtained to rule out
pancreatitis. Moderate serum elevations may accompany obstruction of the common bile duct, pancreatic duct, or ampulla of
Vater; pancreatic injury from a perforated peptic ulcer; pancreatic cancer; and acute salivary gland disease. Impaired kidney
function may increase serum levels.
 Levels may be slightly elevated in a patient who is asymptomatic or responds unusually to therapy.
Decreased levels can occur in chronic pancreatitis, pancreatic cancer, cirrhosis, hepatitis, and toxemia of pregnancy.

ANTINUCLEAR ANTIBODIES

In conditions such as systemic lupus erythematosus (SLE), scleroderma, and certain infections, the body’s immune system may
perceive parts of its own cell nuclei as foreign and may produce antinuclear antibodies (ANAs). Specific ANAs include
antibodies to deoxyribonucleic acid (DNA), nucleoprotein, histones, nuclear ribonucleoprotein, and other nuclear constituents.
Because they don’t penetrate living cells, ANAs are harmless, but they sometimes form antigen–antibody complexes that cause
tissue damage (as in SLE). Because several organs may be involved, test results aren’t diagnostic and can only partially confirm
clinical evidence.

PURPOSE
◆ To screen for SLE (The absence of ANAs essentially rules out active SLE.)
◆ To monitor the effectiveness of immunosuppressive therapy for SLE

PATIENT PREPARATION
◆ Explain to the patient that this test evaluates the immune system and that further testing is usually required for diagnosis.
◆ Inform the patient that the test will be repeated to monitor his response to therapy, if appropriate.
◆ Inform the patient that he need not restrict food or fluids.
◆ Explain that the test requires a blood sample, and tell the patient when and where it will be taken.
◆ Check the patient’s history for drugs that may affect test results, such as isoniazid and procainamide. Note the findings on the
laboratory request.

Reference values
Test results are reported as positive (with pattern and serum titer noted) or negative.

ABNORMAL FINDINGS
Although this test is a sensitive indicator of ANAs, it isn’t specific for SLE. Low titers may occur in patients with viral
diseases, chronic hepatic disease, collagen vascular disease, and autoimmune diseases, and in some healthy adults; the incidence
increases with age. The higher the titer, the more specific the test is for SLE. The titer commonly exceeds 1:256.
The pattern of nuclear fluorescence helps identify the type of immune disease present. A peripheral pattern is almost
exclusively associated with SLE because it indicates anti-DNA antibodies; sometimes anti-DNA antibodies are measured by
radioimmunoassay if ANA titers are high or if a peripheral pattern is observed. A homogeneous, or diffuse, pattern is also
associated with SLE and related connective tissue disorders. A nucleolar pattern is associated with scleroderma, and a speckled,
irregular pattern is associated with infectious mononucleosis and mixed connective tissue disorders (for example, SLE).
A single serum sample, especially one collected from a patient with collagen vascular disease, may contain antibodies
to several parts of the nucleus of the cell. In addition, as serum dilution increases, the fluorescent pattern may change because
different antibodies are reactive at different titers.