Evaluation of Liver

Function
• The liver is composed of three systems:
1. the hepatocyte - concerned with metabolic
reactions, macromolecular synthesis, and
degradation and metabolism of antibiotics
2. the biliary system - involved with the metabolism
of bilirubin and bile salts
3. the reticuloendothelial system - concerned with
the immune system and the production of heme
and globin
Most common causes of acute liver injury - viral hepatitis,
mainly hepatitis A, B, and C, all of which induce acute
elevations of serum alanine and aspartate aminotransferase.

Diagnosis of viral hepatitis can be made by screening for viral

antigens, especially in hepatitis B, and for immunoglobulin M
and G directed against specific viral antigens.

Confirmation of the diagnosis of a particular form of viral

hepatitis is carried out using suitable molecular diagnostic
techniques such as real-time PCR using primers encoding
specific viral gene sequences.
NORMAL LIVER FUNCTION
The liver is the largest and most complex organ of the gastrointestinal
tract.
it comprises three systems:
1. the biochemical hepatocytic system, which is responsible for the vast
majority of all metabolic activities in the body, including protein
synthesis; aerobic and anaerobic metabolism of glucose and other
sugars; glycogen synthesis; amino acid and nucleic acid metabolism
2. the hepatobiliary system, which is concerned with the metabolism of
bilirubin, a process that involves transport
of bilirubin into the hepatocyte and its conjugation to glucuronic acid
and its secretion into bile canaliculi and the enterohepatic system.
3. the reticuloendothelial system —that is, Kupffer cells, these are a
form of macrophage involved (a) with the immune system, including
being a major site of defense against intestinal bacteria and the primary
location for removal of antigen–antibody complexes from the circulation
METABOLIC FUNCTIONS
Bilirubin
Normal Bilirubin Metabolism
• Bilirubin is the major metabolite of heme, the iron-binding
tetrapyrrole ring found in hemoglobin, myoglobin, and
cytochromes. Approximately 250 to 350 mg of bilirubin is
produced daily in healthy adults, about 85% of which is
derived from turnover of senescent red blood cells

• Bilirubin, bound mainly to albumin, is then transported mainly

in the portal system to the liver, where it enters the
hepatocyte through its membrane surface
• Conjugated bilirubin, being water soluble, can be filtered by
the glomerulus and can appear in urine, where it may be
detected by dipstick examination

• Urobilinogen measurement, however, adds little to standard

tests of liver function or injury

• Urinary bilirubin is elevated in most patients with increased

serum conjugated bilirubin
 Causes of Elevated Serum Levels of
Unconjugated Bilirubin
• 1. Hemolysis – unconjugated bilirubin rises as a result of
abnormally high levels of hemoglobin released from
erythrocytes. This is particularly likely to occur in neonates,
whose glucuronyl transferase activity is low.
• 2. Gilbert’s syndrome and the Crigler-Najjar syndrome
In Gilbert’s syndrome - a significant percentage of males with this
defect were found to have hyperbilirubinemia, typically elevated
to 2 to 3 mg/dL
Crigler-Najjar syndrome - unconjugated hyperbilirubinemia
becomes marked, almost always exceeding 5 mg/dL and causing
jaundice, and sometimes exceeding 20 mg/dL. Affected infants
develop severe unconjugated hyperbilirubinemia, which typically
leads to kernicterus
Causes of Elevated Serum Levels of
Conjugated Bilirubin
• 1. Excretion deficits: Dubin-Johnson syndrome - there is a
blockade of the excretion of bilirubin into the canaliculi,
caused by defects in the adenosine triphosphate (ATP)-binding
cassette (ABC) canalicular multispecific organic anion
transporter

• 2. Biliary obstruction - cholelithiasis is the most common

cause of hyperbilirubinemia, ascending cholangitis,
 Laboratory Tests for Bilirubin
• Bilirubin is typically measured using diazotized sulfanilic acid, which forms a
conjugated azo compound with the porphyrin rings of bilirubin, resulting in
reaction products that absorb strongly at 540 nm
• The accuracy of direct bilirubin assays is dependent on sample handling and
reagent composition.
• Typically, direct bilirubin should measure 0 to 0.1 mg/dL in normal
individuals, with rare values of 0.2 mg/ dL in the absence of liver or biliary
tract disease.
• Reference values for total bilirubin are both age and gender dependent.
• Bilirubin levels typically reach peak values at around ages 14 to 18, falling to
stable adult levels by age 25
• Values are higher in males than in females at all ages
• Strenuous exercise causes a significant increase in bilirubin values compared
with those seen in sedentary individuals or those with chronic exercise
• African Americans have bilirubin levels significantly lower than those of
other ethnic groups.
 SYNTHETIC FUNCTIONS
• Protein Synthesis
• The liver is the site of synthesis for most plasma proteins. Major
exceptions include immunoglobulins (Igs) and von Willebrand
factor. Synthesis of more than 90% of all protein and 100% of
albumin occurs in the liver.

• Thus extensive destruction of liver tissue will result in low serum

levels of total protein and albumin. In cirrhosis, besides hepatocyte
destruction, another cause of diminished protein production is
portal hypertension, which decreases delivery of amino acids to the
liver.
• Albumin
• Albumin is the major protein produced by the
liver. Its synthesis is increased by low plasma
oncotic pressure and is decreased by cytokines,
particularly interleukin-6. Although normal
albumin synthesis occurs at about 120
mg/kg/day, the rate of synthesis can
approximately double with low oncotic pressure.
• A decrease in albumin is one of the major
prognostic features in patients with cirrhosis
 Other Serum Proteins
α-1-Antitrypsin.
• α-1-antitrypsin (AAT), the most abundant α-1- globulin, is the most important
protease inhibitor in plasma. Although its name indicates that it inhibits
trypsin, it also is an inhibitor of other serine proteases, such as elastin.

Ceruloplasmin.
• The major copper-containing protein in serum, ceruloplasmin is also the
enzyme present in highest circulating concentration.
• Ceruloplasmin is a ferroxidase, which is essential for converting iron
• to the ferric state to allow binding to transferrin.
• Low levels of ceruloplasmin are found in Wilson’s disease, a rare congenital
disorder (1 in 30,000 individuals) associated with one of many mutations in
the gene on chromosome 13 coding for a cellular adenosine triphosphatase
(ATPase), ATP7B, a member of the cation-transporting p-type ATPase family.
Clotting Factors
• coagulation proteins are synthesized in the liver.
• In addition, inhibitors of coagulation, such as antithrombin
III, α-2-macroglobulin, α-1-antitrypsin, C1 esterase inhibitor, and
protein C, are synthesized in the liver.
• In addition, fibrin degradation products are catabolized in the
liver. Low levels of antithrombin III in patients with cirrhosis
and hepatitis may be caused by decreased synthesis, increased
consumption, or alteration in the transcapillary flux
• The most common coagulopathy seen in liver failure (i.e.,
cirrhosis
• and acute fulminant hepatic failure) is disseminated
intravascular coagulopathy (DIC)
TESTS OF LIVER INJURY
Aminotransferases (Transaminases)
• Two diagnostically very useful enzymes in this category are AST or aspartate
amino transferase, also known as serum glutamate oxaloacetate
transaminase, and ALT or alanine amino transferase, formerly called serum
glutamate pyruvate transaminase.
Lactate Dehydrogenase
• this cytosolic glycolytic enzyme catalyzes the reversible oxidation of lactate
to pyruvate.
• Five major LD isozymes exist, consisting of tetramers of two forms, H and M
• Progressing from HHHH to MMMM, the five possible isozymes are labeled
LD1 to LD5.
LD1 and LD2 predominate in cardiac muscle, kidney, and erythrocytes.
LD4 and LD5 are the major isoenzymes in liver and skeletal muscle.
• Serum LD levels become elevated in hepatitis; often, these increases
are transient and return to normal by the time of clinical presentation
Alkaline Phosphatase
• ALP in the liver, which has a half-life of about 3 days, is a
hepatocytic enzyme that is found on the canalicular surface
and is therefore a marker for biliary dysfunction.
• The bone isozyme is particularly heat labile, allowing it to be
distinguished from the other major forms. In addition, small
intestinal and placental ALP is antigenically distinct from liver,
bone, and kidney ALP.
• In obstruction of the biliary tract by stones in the ducts or
ductules, or by infectious processes resulting in ascending
cholangitis, or by space occupying lesions, biliary tract ALP
rises rapidly to values sometimes in excess of 10 times the
upper limit of normal
TESTING FOR VIRAL-INDUCED
HEPATITIS
Hepatitis A
• Hepatitis A virus (HAV) is a member of the picornavirus family
of RNA viruses. It is transmitted by the fecal–oral route and
typically has an incubation period of 15 to 50 days, with a
mean time of about 1 month, depending on the inoculum
• The initial immune response to the virus is IgM anti-HAV,
which typically develops about 2 to 3 weeks after infection
• IgM antibodies typically persist for 3 to 6 months after
infection. The presence of elevated titers of IgM anti-HAV is
considered to be diagnostic of acute infection
• IgG antibodies develop within 1 to 2 weeks of IgM antibodies
and typically remain positive for life
Hepatitis B
• Hepatitis B virus (HBV) is a member of the hepadnavirus
family, a group of related DNA viruses that cause hepatitis in
various animal species.
• Hepatitis B is transmitted primarily by body fluids, especially
serum.
• It is spread effectively by sex and can be transmitted from
mother to baby.
• Hepatitis B produces several protein antigens that can be
detected in serum: a core antigen (HBcAg), a surface antigen
(HBsAg or HBs), and an e antigen (HBeAg), related to the core
antigen
• The newest assay to assess HBV infection is the ultrasensitive
quantitative real-time PCR technology
• In most individuals, HBV hepatitis is self-limited, and the
patient recovers
• The frequency of chronic HBV infection is 5% to 10% in
immunocompromised patients and 80% in neonates, with the
likelihood of chronic infection declining gradually during the
first decade of life.
• With recovery from acute infection, HBsAg and HBcAg
disappear, and IgG anti-HBs and IgG anti-HBe appear
• Development of anti-HBs is typically the last marker in
recovery and is thought to indicate clearance of virus. Anti-HBs
and anti-HBc are believed to persist for life, although in about
5% to 10% of cases, anti-HBs ultimately disappears
Hepatitis C
• Hepatitis C (HCV) is an RNA virus of the flavivirus group
consisting of an icosahedral viral protein coat, embedded in
cellular lipid and surrounding RNA.
• HCV, formerly known as non-A, non-B hepatitis, is the primary
etiologic agent, transmitted via blood transfusions and
transplantation before 1990.
• At present, 60% of all new cases occur in injection drug users,
but other serum modes of transmission are also seen, such as
accidental needle punctures in health care workers, dialysis
procedures in patients, and, rarely, transmission from mother
to infant
• The primary test for confirming persistence of HCV infection is
HCV RNA, detected by a variety of amplification techniques
Hepatitis C (HCV)–Induced Hepatocellular Carcinoma
(HCC)
• Approximately 20% of patients who have hepatitis C develop
cirrhosis of the liver, which has been attributed to chronic
inflammation due to chronic hepatitis C infection
• It has been found that expression of individual hepatitis C
proteins in normal hepatocytes can lead to their malignant
transformation.
Hepatitis D
• Hepatitis D (delta-agent; HDV) is an RNA virus that can
replicate only in the presence of HBsAg; circulating viral
particles have viral RNA inside a shell of HBsAg
• If HDV infection occurs in the presence of persistent HBV
infection (superinfection), progression of disease may be
faster.
• The major diagnostic test is the presence of anti-HDV
Hepatitis E
• Hepatitis E (HEV), an RNA virus, now classified as a hepevirus, with
a clinical course similar to that of HAV infection
• Similar to HAV, it is spread by the fecal–oral route.
• HEV infections range from inapparent illness to severe acute
hepatitis, sometimes leading to fulminant hepatitis and death.
• The signs and symptoms cannot be distinguished from those
associated with cases of acute hepatitis caused by other
hepatotropic viruses
• Two serologic tests are available: anti-HEV IgM, which detects
recent or current infection, and anti-HEV IgG, which detects
current or past infection
• A PCR amplification of an HEV RNA-specific product using serum,
plasma, bile, or feces becomes the definitive indicator of acute
infection.
Hepatitis G
• Two other viruses have been suspected, but not proven, to
cause posttransfusion hepatitis: hepatitis G virus (HGV,
sometimes called G-B) and transfusion-transmitted virus
• Although acute and chronic HGV can be detected at some
research centers with a qualitative PCR assay for HGV RNA, no
routine testing is recommended because the clinical
significance of HGV remains unknown
 DIAGNOSIS OF LIVER
DISEASES
• It is important to remember that in acute hepatitis, the principal
changes include significant elevations of aminotransferases; in
cirrhosis, these tend to remain normal or become slightly elevated,
while total protein and albumin are depressed, and ammonia
concentrations in serum are elevated.
• In posthepatic biliary obstruction, bilirubin and alkaline
phosphatase become elevated; in space-occupying diseases of the
liver, alkaline phosphatase and lactate dehydrogenase are
elevated.
• In fulminant hepatic failure, the aminotransferases and ammonia
are elevated, but total protein and albumin are depressed.
HEPATITIS
• The most common cause (>90% of cases) of hepatitis is viral, with
about 50% of cases due to hepatitis B, 25% to hepatitis A, and 20%
to hepatitis C.
• The cause of acute hepatitis is likewise almost always (>90% of
cases) viral, although chemical exposure such as to carbon
tetrachloride or chloroform or to drugs such as acetaminophen,
especially in children, should be considered
• The cardinal finding in hepatitis is a rise in the aminotransferases
to values greater than 200 IU/L and often to 500 or even 1000 IU/L.
• An exception to this finding is seen in hepatitis C, in which only
modest elevations of ALT (but not AST) can occur. The AST/ALT
ratio generally favors ALT.
• The bilirubin is frequently elevated and is composed of both direct
and indirect types.
Chronic Hepatitis
• In chronic hepatitis, hepatocyte damage is ongoing, and
chronic inflammation is seen in hepatocytes on biopsy. This
condition is caused mainly by chronic hepatitis B or C
infection, detected by persisting HBsAg or real-time PCR for
hepatitis C sequences, respectively, and is a major
predisposing factor for cirrhosis and hepatocellular carcinoma,
the two leading causes of death from liver disease.

• A mild elevation of AST and ALT is seen, and, more commonly

in hepatitis C, a mild elevation of only ALT may be noted.
CIRRHOSIS
• Cirrhosis of the liver is a condition that results in parenchymal
fibrosis and hepatocytic nodular regeneration and can be caused
by alcoholism or panhepatic hepatitis, chronic active hepatitis,
toxins and drugs, and diseases of the biliary tract, such as primary
and secondary biliary cirrhosis
• In addition, systemic disease can predispose to cirrhosis.
• In hemochromatosis, excess iron becomes deposited in a variety of
tissues, including liver, and becomes toxic to hepatocytes,
predisposing to cirrhosis.
• Chronic hepatitis due to persistent circulating hepatitis B or C virus
and autoimmune disease with elevated ANA or ASMA also
predispose to cirrhosis
• In general, irrespective of the cause, cirrhosis is a chronic but
gradually worsening condition that can occasionally progress to
fulminant hepatic failure
 Diagnosing and Following Cirrhosis, Fibrosis, and
Necroinflammation of the Liver Noninvasively
Using Serum Analytes
• The definitive diagnosis of fibrosis and/or necrosis and
inflammation of the liver is attained by liver biopsy
• This invasive procedure carries with it morbidity such as bleeding
and pneumothorax, and because the liver biopsy itself has the
confounding problem of sampling errors, a search is under way to
devise methods to diagnose and follow these disease processes
noninvasively using the levels of serum analytes that measure liver
function.
• The first of these was the PGA index computed from the PT and
from serum levels of γ-glutamyl transferase and apolipoprotein A-I.
Ranges of values for each of these analytes are divided into five
categories, numbered 0 to 4, in increasing order of severity.
• Higher PGA scores have been found to correlate with the
degree of hepatic fibrosis and with the severity of cirrhosis as
judged both by clinical grading and from liver biopsies
MELD System
• The purpose is to compute the probability of survival for
patients with liver disease.
• The purpose is to compute the probability of survival for
patients with liver disease.
POSTHEPATIC BILIARY
OBSTRUCTION
• Post-hepatic biliary obstruction refers to blockage of the
intrahepatic and extrahepatic ducts and/or to blockage of
bilirubin excretion from the hepatocyte into the canaliculi,
leading to backflow of bile into the hepatocyte and ultimately
into the circulation

SPACE-OCCUPYING LESIONS
• In space-occupying lesions of the liver, a high percentage of which
are due to metastatic cancer; a smaller percentage to lymphoma,
primary hepatocellular carcinoma, and angiosarcoma of the liver;
and a small percentage to benign lesions such as hemangioma of the
liver, the cardinal finding is isolated increases in the two enzymes LD
and alkaline phosphatase
FULMINANT HEPATIC
FAILURE
• In acute fulminant hepatic failure, an uncommon but highly
fatal condition, massive destruction of liver tissue results in
complete liver failure.
• Diagnostic laboratory findings for fulminant hepatic failure
include rapid increases in serum levels of the
aminotransferases to markedly elevated levels, such that AST,
which can reach levels greater than 20,000 IU/L, may be at
least 1.5 times greater in value than ALT because of acute
release of mitochondrial AST
• Patients whose AST and ALT undergo the stereotypic changes
described should be observed closely for fulminant hepatic
failure, especially if there is any indication of encephalopathy.
END