1. Recommended Reading Lecture Notes in Clinical Biochemistry 7th Edition
G Beckett, S Walker, P Rae, P Ashby (Blackwell publishing)
Clinical Chemistry 6th Edition
W J Marshall, S K Bangert (Pubslished by Mosby)
An illustrated Colour text - Clinical Biochmeistry 3rd edition
Alan Gaw et al (Churchill Livingston)
Handbook of Clinical biochmeistry 1st Edition
R Swaminathan (Oxford University Press)
Clinical Chemistry in diagnosis and treatment
Philip Mayne (Edward Arnold)
A Guide to Diagnostic Clinical Chemistry 3rd Edition
Walmsely & White (Blackwell)

2. Clinical Biochemistry of Liver Disease
Dr Vivion Crowley
Consultant Chemical Pathologist
St James’s Hospital

3. Illustrative case History
75 yr old female presented to her GP
C/O dyspepsia and “back “ pain
Background hx:
Breast Ca – Rx with mastectomy, Tamoxifen
Variegate Porphyria
Type 2 Diabetes mellitus
Subclinical Hypothyroidism
GP requested Liver Function Tests (Liver Profile)

4. Albumin 43 (34-48) g/L
Total Bilirubin 7 (0 – 21) umol/L
Alkaline Phosphatase 67 ( ) IU/L
GGT 93 (5 – 36) IU/L
Alanaine transaminase (ALT) 40 (6 – 31) IU/L

5. In view of abnormal LFTs the GP ordered further investigations
Anti Smooth Muscle abs - neg
Anti Mitochondrial abs - neg
Alpha-1 Antitrypsin 1.5 (0.9 – 2.0) g/L
Caeuroloplasmin (20 – 60) mg/dl
Transferrrin Saturation 34% (15 – 45) %
PT 14.8 (11.5 – 15.0) s
APTT s (25 – 35) s

6. GP requested imaging studies in view of negative blood tests
Ultrasound of abdomen and pelvis
Liver
Diffuse inhomogenous somewhat echogenic texture
No focal lesion
Bile ducts not dilated
CT scan of abdomen
Normal size
Subcapsular surface of the liver has a nodular outline
Liver texture has a diffuse slightly coarse appearance
Appearances consistent with Cirrhosis

7. Learning Point
The only indicator for the presence of underlying cirrhosis in this patient were her mildly abnormal LFTs

8. What are the functions of the liver?
Key role in intermediary metabolism
e.g. gluconeogenesis, glycolysis, ketogeneis, lipid synthesis
Protein synthesis – including many plasma proteins and blood
clotting factors
Bile secretion and role in digestion
Primary site of xenobiotic detoxification -drug and toxin metabolism
Ureagenesis - ? Role in acid-base balance

9. What are Liver Function Tests (LFTs)
Total Bilirubin
Conjugated vs. Unconjugated
Anion transport
Alkaline Phosphatase (ALP)
-Reference range varies with age – higher in childhood
and adolescence
Isoenzymes e.g. bone, liver, intestine, malignancy
Bile flow
Gamma-glutamyl transferase (GGT)
-Sensitive indicator of liver disorder
-Cholestasis
-Induced by many drugs and toxins e.g. C2H5OH,
pheytoin, barbiturates, ? statins

10. Transaminases
-Alanine aminotransferase (ALT)
-Aspartate aminotransferease (AST)
-ALT is more liver specific
-AST is also found in cardiac and skeletal muscle
-Hepatocellular integrity
Albumin
- Plasma transport protein
Assesses Protein synthesis in liver
Prothrombin time
Extrinsic pathway of coagulation
Reflects protein synthetic function

11. What role do LFTs in clinical management ?
Detecting the presence of liver disease
Indicating the broad diagnostic category of the liver disease
Monitoring treatment

12. Specialised Liver-related tests
Viral Hepatitis Screen – A, B, C etc.
Autoimmune Heaptitis screen – AMA, ASMA,
Serum protein electrophoresis
α1- antitrypsin
α fetoprotein (AFP)
Transferrin Saturation/Ferritin/HFE Genotyping
Caeruloplasmin, Plasma/Urine Copper
Ultrasound scan, CT, MRI
Biopsy

13. Clinical History C2H5OH Hx
Family Hx – Haemochromatosis, Wilson Disease,
Drug Hx – What medication is the patient taking?
Travel Hx – Recent travel, Blood transfusions

14. Bilirubin production and metabolism
UDP
Glucoronosyl
transferase

15. Hyperbilirubinaemia Jaundice evident with Bilirubin levels 35-70μmol/L
Normally 95% of plasma bilirubin is unconjugated
Conjugated – Hepatic/posthepatic
(Bilirubinuria)
Hepatocellular diseases
Cholestatic diseases
Dubin-Johnson**
Rotor’s syndrome**
Unconjugated - prehepatic
*(No bilirubinuria)
Haemolyis
Resolving haematoma
Gilbert’s Syndrome
Crigler-Najjar syndrome
*Except in Nephrotic syndrome
**Benign congenital conjugated hyeprbilirubinaemia

17. Gilbert’s Syndrome Present in 5% of the population Males > females
Genetic origin
– insertion of TA in promoter region of UGT-1A gene
Exacerbated by fasting and illness
Confirm conjugated hyperbilirubinaemia
Rule out haemolysis FBC, Reticulocyte count
Rule out underlying liver disease -

18. Causes of neonatal jaundice
Unconjugated bilirubin level > 300μmol/L may be associated
with Kernicterus (brain damage due to uptake of unconjugated bilirubin)

19. Patterns of LFTs Hepatocellular Predominant elevation in AST/ALT –
Cholestatic
Predominant elevation in ALP with GGT ± Bilirubin
Mixed
Elevation in both AST/ALT, and ALP/GGT ± Bilirubin

20. Causes of a Hepatocellular Pattern of LFTs
Marked elevations in ALT/AST > x5 URL
(patient likely to be symptomatic)
Viral hepatitis
Ischaemic hepatitis
Autoimmune hepatitis
Drug/toxins e.g. alcoholic hepatitis
Mild/Moderate elevations in ALT/AST < x5 URL
(patient may be asymptomatic)
Chronic Hepatitis
ALD
NAFLD/NASH – associated with obesity, T2DM, Hyerlipidaemia
Metabolic liver disease - HH, WD, A1AT
Drugs
Autoimmune LD

21. Approach to an asymptomatic patient with elevated ALT/AST
Elevated AST/ALT
Repeat test
? Muscle
problem
Still Elevated
Normal
Check CK
Elevated
Normal
Likely Liver Aetiology
Drug Hx etc
Viral serology
AI hepatitis screen
Fe/TIBC/Ferritin/HFE genotyping
Caeuruloplasmin if < 40 yr
A1AT
Coeliac screen
Ultrasound scan
MRI/CT Bx

22. Causes of a Cholestatic Pattern of LFTs
Elevated ALP and GGT ± Bilirubin, relative to transaminases
Extrahepatic
(Bilirubin elevated)
Cholelithiasis (CBD)
Malignancy – HOP,
Primary sclerosing cholangitis
Intrahepatic
(Bilirubin not elevated)
Medications
TPN
Sepsis
Postoperative
PBC
Alcoholic hepatitis
Liver mets
Pregnancy-related
CCF
GGT is useful in differentiating Liver as a cause of elevated ALP

23. An approach to the patient with isolated elevation in ALP
Elevated ALP
Normal
What is GGT?
Elevated
?bone, placenta,
Intestine etc.
US/CT/MRI
No abnormality
Biliary dilation
Focal mass
Medications
Consider other
causes
PBC
-AMA
Specialised investigations

24. Other LFTs Serum ammonia
used for investigation of hepatic encephalopathy
-lacks sensitivity and specificity
-useful for investigation of urea cycle disorders
Serum LDH
-included in LFTs in SJH
-5 isoenzymes – heart, erythrocytes, skel mus, liver, others
-not specific for liver - ? role in ischaemia-related abnormal LFTs
-useful in monitoring certain malignancies e.g. B-cell lymphoma
- “not really a LFT”

25. Reference Ranges for LFTs Biochemistry Department, St James’s Hopsital
Albumin
35-50 g/L
Bilirubin
<17 umol/L
ALP*
IU/L*
AST
7-40 IU/L
ALT
7-35 IU/L
GGT
10-55 IU/L
* NB: Reference Range is age related

26. Case 1 24 yr old male Insurance medical showed abnormal LFTs ? Cause
Albumin
42 (35-50 g/L)
Bilirubin
38 (<17 umol/L)
ALP
98 ( IU/L)
AST
30 (7-40 IU/L)
ALT
28 (7-35 IU/L)
GGT
37 (10-55 IU/L)
What further tests are indicated?
What is the most likely cause of raised Bilirubin?

27. Case 2 35 yr old female with a 4/52 hx of
malaise, anorexia, upr abdominal pain, ?haematuria
O/E Icteric
Alb 35
Bilirubin
126
ALP
250 (40-120)
AST
1459
ALT
2009
GGT
331
What further investigations are indicated?
What fraction of her bilirubin is elevated and how does this
impact on her “haematuria”?

28. Case 3 You are phoned about the following results and asked to
comment on the ALP which appears to be elavated?
Pt is a 17 yr old male – clinical details “still growing”
Alb 46
Bilirubin 12
ALP
220 (40-120)
AST 20
ALT
GGT 9
What is the likely cause for the elevated ALP?
Which isoenzyme is increased?

29. Case 4 48yr old female is attending a lipid-clinic
polygenic hypercholesterolaemia
On atorvastatin 20mg/d for 2 years
C/o tired fatigue, malaise
Alb 42
TBilirubin 8
ALP
250 (40-120)
AST 38
ALT 26
GGT
220
LFTs measured 6/12 previously were normal
What further investigations would you perform?
What is the differential diagnosis?

30. Case 5 Fasting Glucose 6.8 mmol/L Alb 38 TBili 15 ALP 82 AST 58 ALT 72
37 yr old male is referred to a lipid clinic with ? Mixed hyperlipidaemia
(Chol 7.0 Trigs 5.2)
BMI 35, WC=120cm
Normotensive
Otherwise clinically well
Fasting Glucose
6.8 mmol/L
Alb 38
TBili 15
ALP 82
AST 58
ALT 72
GGT
67 (<55)
What further investigations would you suggest and why?

31. Case 6: Background
Phonecall from a GP regarding LFTs
72yr old female with discomfort in R hypochondrium
No other hx of note
Not on medications
No C2H5OH

32. Case 6: LFTs
28/4
3/5
Alb (35-50) 39
Tbili (3-17) 10 6
AST (7-40)
113
106
ALT (7-35) 95
Alk Phos (40-120)
352
372
GGT (5-40)
874
930
LDH ( )
426
495
CK (34-170) 82

33. Case 6: Further investigations
Mixed cholestatic and hepatocellular liver disease
Fe, TIBC, TS% - all normal
Hepatic Antibody screen – negative
Ultrasound of Upr Abdomen recommended
Gallstones diagnosed

34. Case 7: Background 6/5 12/5 Alb 45 43 TBili 181 242 Alk Phos 454 408
47 yr old male
Hx – malaise and ?icterus (confirmed in sclera)
No recent hx C2H5OH excess or medication
6/5
12/5
Alb 45 43
TBili
181
242
Alk Phos
454
408
GGT
813
428
AST
344 75
ALT
707

35. Case 7: Dx
Predominant hepatitic picture
Resolving to cholestatic LFTs
Probable acute viral hepatitis

36. Case 8 7/3 4/4 Alb 51 50 Tbili (3-17) 93 48 Conj Bili 9 Alk Phos 74 84
24 yr old male
Vague hx of feeling unwell, also wt loss >7Kg
? Eating disorder/psychiatric illness
7/3
4/4
Alb 51 50
Tbili (3-17) 93 48
Conj Bili 9
Alk Phos 74 84
GGT 14 18
AST 25 23

37. Case 8: Further Investigations
FBC and Reticuloctye count – normal
Viral Hep screen – normal
Hep antibody screen – normal
U/S – normal
Biochmeical Dx:
-unconjugated Hyeprbilirubinaemia (Gilbert’s syndrome)
-confirmed by genetics

38. Case 9: Why the elevated LFTs?
52 yr old male
No medical hx of note
Not on regular medications
Non-specific hx
Routine Bloods done by GP
“Family Hx IHD” written on request form

39. Case 9: Results Fasting Lipid and Glucose – unremarkable
AST = 243, LDH = 1525 ( )
GGT = 85 (10-55) other LFTs normal
GP surprised at the raised AST
? Further investigations

40. Case 9: Further Investigations
ALT = 50 (7-35)
CK 1191 (29-195)
CK-MBmass = 132 (<12)
CK-MB fractionation 10% (<6%)

41. Case 9: Dx GP practice contacted:
-Informed by Registrar that results were of concern
-needed to be communicated to GP
-1day later Consultant phoned to see if action had been taken
-Pt contacted and advised to present to A/E SJH
Troponin T = 3.25 (<0.01)
Acute Coronary Syndrome (Acute MI)
PTCA and stenting performed

42. Paracetamol Overdose Hepatic necrosis observed within 36-72 hours
Accumulation of breakdown product NAPQI

43. Early diagnosis and treatment of paracetamol OD is essential
Ideally before 12 hours post ingestion
N-acetylcysteine (Parvolex) is an effective agent

44. Iron Overload Syndromes
Primary:
Hereditary Haemochromatosis (HH)
Secondary:
Non HH Cirrhosis
Ineffective erythropoiesis – sideroblastic anaemia, Thalassaemia
Multiple transfusions
Bantu siderosis
Porphyria Cutanea Tarda (PCT)

45. Hereditary Haemochromatosis
Autosomal recessive
Mutations in HFE gene
C282Y
H63D
93% associated with homozygosity C282Y +
6% associated with compound heterozygosity C282Y + H63D
1% No mutations identified

46. Clinical presentation of HH
Males > females
Usually in middle age
Clinical presentation caused by iron accumulation in
Liver – fatty change Cirrhosis
Pancreas – Diabetes
Heart – dilated cardiomyopathy
Joints – arthropathy
Pituitary – secondary hypogonadism (males > females0
Testses – primary hypogonadism (rarer)
Parathyroid - hypocalceamia

47. Diagnosis of HH Increased Transferrin Saturation (Plasma Fe/TIBC)
55% - genotype
45-55% - may consider genotype
Increased Ferritin
HFE genotype
Liver Biopsy
Liver Iron content

48. Figure A C282Y H63D 1 2 3 1 2 3 Homozygous mutant Heterozygous
Homozygous mutant
Heterozygous
Wild type (normal)
Homozygous mutant
Heterozygous
Wild type (normal)

49. Case Example : Haemochromatosis Total protein 71 Total Bilirubin 14
51yr old male
Total protein 71
Total Bilirubin 14
Alk Phos 82
GGT 39
AST 44
ALT 92
Serum Fe 38
TIBC 41
Transferrin sat
93%
Ferritin
1,316
HFE genotype C282Y homozygous –Hereditary Haemochromatosis

50. Wilson disease Autosomal recessive Associated with mutations in ATP7B
(Cu transporting P type ATPase)
Clinical presentation – Children and adults usually < 40 years
CNS – extrapyramidal system, Kayser-Fleischer rings in cornea
Liver – fatty liver, cirrhosis,acute fulminant hepatic failure
Kidney, Haemolytic anaemia
Dx:
Low plasma caeruloplasmin
Increased Urinary Cu excretion (Penicillamine Challenge Test)
Liver Bx – measure Cu content