LIVER FUNCTION TESTS Mitchell L. Shiffman, MD Director Liver Institute of Virginia Bon Secours Health System Richmond and Newport News, VA Liver Institute of Virginia Education, Research and Treatment for Patients with Liver Disease Bon Secours Health System LFTs DO NOT MEASURE FUNCTION Aspartate aminotransferase (AST) Alanine aminotransferase (ALT) Alkaline phosphatase (ALP) Should be referred to as liver chemistries or enzymes October 212 1
LIVER TESTS CATEGORIES Category Inflammation Cholestasis Synthesis Metabolism Other Test Aspartate aminotransferase (AST) Alanine aminotransferase (ALT) Alkaline phosphatase (ALP) Serum albumin Pro-thrombin (INR) Bilirubin Platelet count Serum creatinine LFTs LIVER ENZYMES LOCATION OF TRANSAMINASES ALT Cytoplasm Injury: ALT>AST Alcohol: AST>ALT Cirrhosis: AST>ALT AST Mitochondria October 212 2
SERUM ALT NORMAL DISTRIBUTION % of Patients 7 6 5 4 3 2 1 Women Men 2 SD above mean 2 4 6 8 ALT (IU/L) E Keeffe et al. Clin Gastroenterol Hepatol 28. D Prati et al. Ann Int Med 22;137:1-1. Eliminate patients with: BMI >25 Increased cholesterol Hypertension Heart disease Diabetes mellitus Any medications LIVER TESTS ORGANS CONTAINING AST AND ALT AST ALT Liver Yes Yes Skeletal muscle Yes Small amounts Heart Yes No Brain Yes No Kidney Yes No October 212 3
HEPATOTOXICITY OR MYOPATHY AST and ALT 2 15 Medication A ALT AST IU/L 1 5-4 4 8 12 16 2 24 WEEKS LIVER TRANSAMINASES AST/ALT RATIO AND HISTOLOGY 2. 1..5 AST/ALT 1.5. CPH None Portal Bridging A B C Fibrosis Stage Cirrhosis ML Shiffman et al. Hepatology 1994;19:933-94. October 212 4
NON-INVASIVE MARKERS OF FIBROSIS APRI APRI 8 6 4 2 1 2 3 4 5 6 APRI = AST/(ULN AST ) x 1 platelet count AST increases with cirrhosis Platelet count declines with cirrhosis Can differentiate cirrhosis from patients t with none-mild fibrosis ISHAK STAGE CT Wai et al. Hepatology 23;38:518-526. NON-INVASIVE MARKERS OF FIBROSIS FIBROTEST Utilizes 5 serum biochemical markers to predict fibrosis Alpha-2 macroglobulin Haptoglobin Gamma glutamyl transpeptidase Total bilirubin Apolipoprotein A1 Markers of inflammation NOT fibrosis October 212 5
ASSESSMENT OF LIVER HISTOLOGY SERUM TESTS 1. 1. FIBROTEST.8.6.4.2 ACTITEST.8.6.4.2. 1 2 3 4. 1 2 3 FIBROSIS STAGE ACTIVITY GRADE T Poynard, et al. Hepatology 23;38:481-492. NON-INVASIVE MARKERS OF FIBROSIS COMPARISON OF TESTS Sensitivity 1.8.6.4 2.2 Fibroscan Fibrotest APRI.2.4.6.8 1 1-Specificity L Castera, et al. Gastroenterology 25;128:343-35. All noninvasive i markers of fibrosis provide similar information All separate mild disease from advanced fibrosisi No test can tell you which patients have no fibrosis and will not progress October 212 6
ALKALINE PHOSPHATASE SITES OF PRODUCTION Liver Bone Intestine Kidney Placenta Tumors Site Hepatocyte cannalicular membrane NOT bile duct cell Lung Ovary ALKALINE PHOSPHATASE VARIATION WITH AGE ALP (IU/ml) 35 3 25 2 15 1 5 ULN Bone ALP during rapid growth and osteoporosis associated with advanced age 1 2 3 4 5 6 7 8 9 1 AGE (years) PL Wolf Arch Pathol Lab Med 1978;12:497-51. October 212 7
ALKALINE PHOSPHATASE EFFECTS OF PREGNANCY 3 AL LP or GGT (IU/L) 25 2 15 1 5 ULN for ALP GGT ALP Baseline 1 2 3 Post -------Trimester------ Pardum Walker et al. Obstet Gynecol 1978;43:745-748. ALKALINE PHOSPHATASE CONFIRMATION OF LIVER ORIGIN Fractionate ALP: Liver I Liver II Bone Intestine Obtain an alternative test: Only helpful when liver transaminases are normal Gamma-glutamyl transferase (GGT) 5 nucleosidase October 212 8
CHOLESTASIS CLINICAL FEATURES Obstructive Jaundice Intrahepatic Cholestasis ALP Elevated Elevated Bilirubin Elevated Normal-Elevated Large bile ducts Dilated Normal Small bile ducts Proliferation Normal-Abnormal Histology Bile lakes Bilirubin stasis CHOLESTASIS OBSTRUCTIVE JAUNDICE Large bile duct obstruction October 212 9
CHOLESTASIS OBSTRUCTIVE JAUNDICE Large bile duct obstruction Bile duct proliferation Elongation of bile duct CHOLESTASIS BILE DUCT PROLIFERATION Observed with: Large bile duct obstruction Primary biliary cirrhosis Sclerosing cholangitis Hepatic regeneration following hepatectomy Not found with: Drug induced cholestasis Infiltrative disorders October 212 1
DRUG INDUCED CHOLESTASIS BILIRUBINSTASIS CHOLESTASIS INTRAHEPATIC CHOLESTASIS Direct effect on cannalicular membrane by: Toxins, metabolites Drugs Interleukins, TNF EtOH ALP translocates to basolateral membrane of hepatocyte Lost to serum ALP October 212 11
CHOLESTASIS EXCRETION OF SUBSTANCES IN BILE Bilirubin Cholesterol Copper Bile salts Increased in serum Fat malabsorption INTRAHEPATIC CHOLESTASIS ETIOLOGIES Medications Infiltrative disorders Hepatic metastasis Alcoholic hepatitis Benign recurrent cholestasis Primary bile duct disorders October 212 12
INTRAHEPATIC CHOLESTASIS INFILTRATIVE DISORDERS Sarcoidosis Amyloidosis Tuberculosis Fungal infections Lymphoma/small cell carcinoma INFILTRATIVE DISORDERS SARCOIDOSIS October 212 13
DRUG INDUCED HEPATOTOXICITY CHOLESTASIS Na + BA - Anion - OH - BA - Anion - Inhibitor of cannalicular transport TOXIN DRUG INDUCED HEPATOTOXICITY CHOLESTASIS NSAIDs H 2 blockers Proton pump inhibitors Phenytoin and other anti-seizure medications Oral hypoglycemic agents Lipid lowering drugs Anti-fungal agents Sulfonamindes Erythrocycin Anti-depressants Haldol, thorazine and other anti-psychotic agents October 212 14
HEPATOTOXICITY PURE CHOLESTASIS IU/L 6 5 4 3 2 AST ALT ALP Itching Medication D Itching Resolves 1-4 4 8 12 16 2 24 WEEKS HEPATOTOXICITY CHOLESTASIS WITH JAUNDICE IU/L 6 1 5 AST ALT 8 4 ALP Tbili 6 3 2 Medication E 4 1 2 T BILI (mg/dl) -4 4 8 12 16 2 24 WEEKS October 212 15
BENIGN RECURRENT CHOLESTASIS FEATURES Episodic pruritus and jaundice First episode always prior to age 3 years Liver histology: Cholestasis during attacks Normal between attacks Normal cholangiography Autosomal dominant trait of FIC-1 protein Positions proteins within cell membrane VA Luketic and ML Shiffman Clin Liv Dis 1999;3:59-528. BENIGN RECURRENT CHOLESTASIS LABORATORY PATTERN ALP (IU/L) 18 6 15 12 9 6 3 pruritus 3 6 9 12 15 18 5 4 3 2 1 GGT (IU/L) ALP GGT Bilirubin MONTHS Adapted from VA Luketic and ML Shiffman Clin Liv Dis 1999;3:59-528. October 212 16
CLOTTING FACTORS SYNTHESIZED BY THE LIVER Vitamin K Dependent Vitamin K Independent Clotting II VII IX X I V VIII Anti-clotting Protein C Protein S Anti-thrombin III Liden Factor 5 PROLONGATION IN PRO-THROMBIN TIME ETIOLOGIES Vitamin K Decreased Prolonged cholestasis Obstructive jaundice Malabsorption Fat malabsorption Chronic antibiotic use Cirrhosis Vitamin K Normal October 212 17
LIVER FUNCTION TESTS COAGULATION PROTEINS Vitamin K dependent and independent Clotting and anti-clotting factors Normally in balance Cirrhosis may alter this balance Factor VII shortest half-life - 6 hours Pro-thrombin time (INR) is the most sensitive of all liver function tests COAGULATION PROTEINS BALANCING CLOTTING FACTORS Measurable (PT/INR) Not Measurable October 212 18
BALANCING CLOTTING FACTORS CLOTTING IN CIRRHOSIS Clotting Anti-clotting Coagulation INR Factors Factors Status Normal Normal 1. Normal -2-2 2. Normal -2 Normal 2. Hypocoagulable -4-2 2 2. Hypocoagulable Normal -2 1. Hypercoagulable -2-4 2. Hypercoagulable BILIRUBIN CONJGATION AND EXCRETION UCBR+ Albumin Conjugation UDP Glucuronyltransferase Albumin Secretion into bile is the rate limiting step CBR October 212 19
LIVER FUNCTION TESTS BILIRUBIN Water Bound to Excreted Soluble Albumin into Conjugated Yes No Urine Bile Unconjugated No Yes Bile Delta Yes Irreversible HYPERBILIRUBINEMIA MECHANISMS Excessive production Unconjugated hyperbilirubinemia Inefficient conjugation Unconjugated hyperbilirubinemia Defective secretion into bile Conjugated hyperbilirubinemia October 212 2
HYPERBILIRUBINEMIA ETIOLOGIES CONJUGATED Hepatocellular dysfunction Acute Chronic Cirrhosis oss Cholestasis Genetic disorders: Dubin-Johnson Rotor UNCONJUGATED Hemolysis Reabsorption of hematoma Genetic disorders: Gilberts Gbetssydo syndrome Crigler-Najjar I Cirgler-Najjar II CONJUGATED HYPERBILIRUBINEMIA GENETIC DEFECTS Dubin-Johnson Syndrome Rotor s Syndrome Bilirubin fluctuates between ULN and 5mg/dl No signs or symptoms of liver disease ALP and GGT are always normal Symptoms of cholestasis are absent Transport of bile and other substances into bile is normal Dark heavily pigmented liver Gallbladder not visualized on oral cholecystogram Liver histology normal Oral cholecystogram is normal October 212 21
UNCONJUGATED HYPERBILIRUBINEMIA CRIGLER-NAJJAR SYNDROME Type I Type II Genetics Autosomal recessive? UDP GT activity Absent 5% of normal Bilirubin levels ~2 + mg/dl ~ 5 mg/dl Kernicturus YES NO Treatment Plasmapheresis Hepatocyte/liver transplant Not needed GILBERT S SYNDROME CHARACTERISTICS The most common cause of jaundice in otherwise healthy persons: Total bilirubin 2-7 mg/dl Nearly all unconjugated bilirubin Autosomal dominant Reduced d conjugation of bilirubin Jaundice worsens during fasting Bilirubin can be reduced with phenobarbital October 212 22
GILBERT S SYNDROME FASTING AND TREATMENT 7 ilirubin (mg/dl) Bi 6 5 4 3 2 1 Baseline Fasting Phenobarbital M Black, et al. Lancet 197;1:1359-1363. LIVER FUNCTION TESTS NON-LIVER TESTS Platelets: A platelet count of <125/cc is the most sensitive test for identification of patients with cirrhosis Serum creatinine: The single most important predictor of 3 day mortality in patients with cirrhosis Serum creatinine > 2.5 mg/dl doubles 3 day mortality October 212 23
NON-LIVER FUNCTION TESTS PLATELET COUNT 25 3 HVPG (mm Hg) 2 15 1 5 Platelet Count (x1/mm 3 ) 25 2 15 1 5 1 2 3 4 PLATELET COUNT ML Shiffman et al. Hepatology 28; (abstract). AJ Sanyal et al. Gastrointest Endosc 26; 64:855-864. 1 2 3 VARICEAL SIZE MODEL OF END STAGE LIVER DISEASE SERUM CREATININE SURVIVAL (%) 1 8 6 4 2 At 3 months 1 2 3 4 MELD SCORE MELD Score based upon: Total bilirubin INR Serum creatinine Creatinine has the strongest weight on mortality in the MELD score calculation. PS Kamath et al. Hepatology 21;33:464-47. October 212 24