High levels of liver in blood work: Normal, Low, and High Ranges & Results
Tips and foods to eat
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The body stores fat in many areas for energy and insulation. The liver partially consists of fat. However, if the fat content in the liver is too high, this may be a sign of fatty liver disease. Dietary changes are the first-line treatment for this liver condition.
There are two types of fatty liver disease: alcoholic liver disease and nonalcoholic fatty liver disease. Pregnancy can also cause fatty liver disease.
Fatty liver disease damages the liver, preventing it from removing toxins and producing bile for the digestive system. When the liver cannot perform these tasks effectively, it puts a person at risk of developing other problems throughout their body.
Dietary changes and regular exercise are key ways to manage fatty liver disease. However, some people may need to see a doctor for further treatment.
In this article, we suggest several foods to include in a diet for fatty liver disease, as well as foods to avoid.
A diet for fatty liver disease should include a wide variety of foods.
Reducing calorie intake and eating high fiber, natural foods is a good starting point. Eating foods that contain complex carbohydrates, fiber, and protein can provide sustained energy and promote satiety.
Foods that reduce inflammation or help the body repair its cells are equally important.
Some people choose to follow specific diet plans, such as a plant-based diet or the Mediterranean diet. A dietitian can often help a person create a customized diet plan that is right for their tastes, symptoms, and health status.
In addition to these basic guidelines, some specific foods may be especially helpful for people with fatty liver disease. These foods include:
Garlic is a staple in many diets, and it may provide benefits for people with fatty liver disease. A 2016 study in Advanced Biomedical Research found that garlic powder supplements appear to help reduce body weight and fat in those who have fatty liver disease.
Read more on the medicinal properties of garlic.
Omega-3 fatty acids
A 2016 review of current research suggests that consuming omega-3 fatty acids improves the levels of liver fat and high-density lipoprotein (HDL) cholesterol levels in people with nonalcoholic fatty liver disease.
Although more research is necessary to confirm this finding, eating foods that are high in omega-3 fatty acids may help lower liver fat. These foods include:
Drinking coffee is a morning ritual for many people. However, it may provide benefits beyond a burst of energy for people with fatty liver disease.
A 2019 animal study found that decaffeinated coffee reduced liver damage and inflammation in mice that ate a diet containing high levels of fat, fructose, and cholesterol.
Another study in mice from the same year showed similar results. The researchers found that coffee reduced the amount of fat that built up in the mice’s livers and improved how their bodies metabolized energy.
Eating a variety of whole vegetables is helpful for people with fatty liver disease. However, broccoli is one vegetable that a person with fatty liver disease should seriously consider including in their diet.
A 2016 animal study in The Journal of Nutrition found that the long-term consumption of broccoli helped prevent the buildup of fat in murine livers.
Researchers still need to conduct further studies involving humans. However, early research into the effect of broccoli consumption on the development of fatty liver disease looks promising.
Using tea for medicinal purposes is a practice that goes back thousands of years.
A 2015 review in the World Journal of Gastroenterology suggests that green tea may help lower levels of fat in the blood and throughout the body. One of the included studies reported reduced levels of fat in the liver in people who consumed 5–10 cups of green tea per day.
Green tea provides several antioxidants, such as catechin, which may help improve fatty liver disease.
While all tree nuts are a great addition to any diet plan, walnuts are especially high in omega-3 fatty acids and may provide benefits for people with fatty liver disease.
A review from 2015 found that eating walnuts improved liver function test results in people with nonalcoholic fatty liver disease.
Soy or whey protein
A 2019 review in the journal Nutrients found that both soy and whey protein reduced fat buildup in the liver.
The results of one study in the review showed that liver fat decreased by 20% in women with obesity who ate 60 grams of whey protein every day for 4 weeks. Soy protein contains antioxidants called isoflavones that help improve insulin sensitivity and reduce the levels of fats in the body.
SHOP FOR THESE FOODS
People can purchase these beneficial foods in grocery stores and online:
Adding healthful foods to the diet is one way to manage fatty liver disease. However, it is just as important for people with this condition to avoid or limit their intake of certain other foods.
Sugar and added sugars
Added sugars contribute to high blood sugar levels and can increase fat in the liver.
Manufacturers often add sugar to candy, ice cream, and sweetened beverages, such as soda and fruit drinks.
Added sugars also feature in packaged foods, baked goods, and even store-bought coffee and tea. Avoiding other sugars, such as fructose and corn syrup, can also help minimize fat in the liver.
Alcohol is the most common cause of fatty liver disease. Alcohol affects the liver, contributing to fatty liver disease and other liver diseases, such as cirrhosis.
A person with fatty liver disease should reduce their intake of alcohol or remove it from their diet altogether.
Here, learn more about the short- and long-term effects of alcohol.
Processed and refined grains are present in white bread, white pasta, and white rice. Producers have removed the fiber from these highly processed grains, which can raise blood sugar as the body breaks them down.
A 2015 study of 73 adults with nonalcoholic fatty liver disease found that those who consumed fewer refined grains had a lower risk of metabolic syndrome — a group of risk factors that increase the likelihood of heart disease and stroke.
People can easily replace refined grains with potatoes, legumes, or whole-wheat and whole-grain alternatives.
Fried or salty foods
Too much fried or salty food is likely to increase calorie intake and the risk of weight gain. Obesity is a common cause of fatty liver disease.
Adding extra spices and herbs to a meal is a great way to flavor foods without adding salt. People can also usually bake or steam foods instead of frying them.
A 2019 review article notes that saturated fat intake increases the amount of fat that builds up around organs, including the liver. Beef, pork, and deli meats are all high in saturated fats, which a person with fatty liver disease should try to avoid.
Lean meats, fish, tofu, or tempeh make suitable substitutes. However, wild, oily fish may be the best choice, as these also provide omega-3 fatty acids.
Regular exercise is important for everyone. However, it provides extra benefits for people with fatty liver disease. Maintaining a healthy body weight with exercise may help a person manage and reduce symptoms.
The American Heart Association recommend at least 30 minutes of moderate exercise five times a week.
Tips for becoming more active include:
- using a standing workstation
- stretching every morning
- walking on a treadmill while watching television
- taking the stairs instead of an elevator
These are all simple ways to increase activity levels throughout the day without having to make time for a full workout.
If diet and exercise are not having the desired effect on the symptoms of fatty liver disease, it may be time to see a doctor. The doctor can run a full analysis and prescribe medications or refer the person to a nutritionist to help them create a diet plan.
No currently approved medications can treat fatty liver disease. Dietary and lifestyle choices, however, can improve the condition significantly.
With the support of a doctor or nutritionist, many people find that they can lose weight and comfortably manage fatty liver disease.
Symptoms, causes, treatment, and outlook
Nonalcoholic fatty liver disease happens when there is too much fat in the liver, or steatosis. The condition is also known as fatty liver.
There may be no symptoms in the early stages, but continued damage to the liver can lead to a more severe condition.
Some people with nonalcoholic fatty liver disease (NAFLD) will develop nonalcoholic steatohepatitis (NASH). This can develop into cirrhosis, or scarring and dysfunction of the liver.
Fatty liver is often related to obesity, high blood pressure, diabetes, and high cholesterol. NAFLD or NASH is not due to high alcohol consumption.
Around 10 to 46 percent of people in the United States have fatty liver but no inflammation or damage. Between 3 and 12 percent have NASH. NAFLD is the most common cause of liver disease in western countries.
Fatty liver can also occur during pregnancy, and cirrhosis can result from alcohol-related liver disease, but NAFLD is considered a separate diagnosis and doctors manage it differently.
Share on PinterestFatty liver disease often occurs with obesity, diabetes, and chronic kidney disease.
The liver is important for removing toxins from the body. If it does not work properly, various symptoms can arise.
If the body produces too much fat, or if the fat is not properly metabolized, it can build up in the liver.
If too much fat builds up in the liver, this can cause fatty liver. If fat continues to accumulate, this can lead, in some cases, to NASH and eventually cirrhosis and liver failure.
At a threshold level, more than 5 to 10 percent of the liver weight is fat.
If more fat than this builds up in the liver, this is known as NAFLD, or simple fatty liver. It is not healthy, but it not necessarily severe enough to cause any problems, and the person will not usually notice any symptoms.
Most people with simple fatty liver will not know they have it. They may only find out after being tested for some other condition, or because other risk factors suggest that a test is a good idea.
Some 30 to 40 percent of adults in the U.S. have NAFLD. However, it is hard to establish an exact figure, as there is no one set of criteria for defining NAFLD.
For most people, the condition does not progress beyond this stage.
If fat continues to build up and the liver becomes inflamed, NASH results. In the U.S., this affects between 3 and 12 percent of adults.
Around 75 percent of patients will have swelling in the liver, or hepatomegaly.
Symptoms may include:
- tiredness and fatigue, including muscle weakness and a lack of energy
- discomfort and possibly swelling in the upper abdomen
- weight loss
- low appetite
The symptoms can be vague, and they can resemble those of a number of other problems. Tests may be carried out to eliminate other conditions.
Scientists are unsure why some people are more likely to develop NASH.
Cirrhosis and liver failure
In time, 10 to 25 percent of people with NASH will develop scarring or fibrosis, also known as cirrhosis, and liver failure.
- tiredness and weakness
- nausea, vomiting, and diarrhea
- tarry stools
- abdominal swelling and pain
- a yellowing of the skin and eyes, known as jaundice
- confusion, difficulty focusing, memory loss, and hallucinations
- itchy skin
- bleeding and bruising easily
In severe cases, a liver transplant may be necessary.
Exactly how and why fatty liver develops is not clear. It occurs when the body produces too much fat, or when it cannot process fat properly.
Obesity is a clear risk factor. Around 70 percent of people with obesity have the condition, while 10 to 15 percent of people with a normal weight have it.
Regardless of their weight, a person with “deep” abdominal fat is more likely to have a fatty liver.
Other risk factors include:
- high cholesterol or high levels of fat in the blood
- high blood pressure
- high blood fats, or triglycerides
People with metabolic syndrome, a condition that involves a clustering of the risk factors mentioned above, are at higher risk.
Between 40 and 80 percent of people with type 2 diabetes have NAFLD.
Researchers have found “growing evidence” that NAFLD is linked to cardiovascular disease (CVD) and chronic kidney disease (CKD).
This means that those with NAFLD are also more likely to have diabetes and heart disease.
While there are clear links between obesity and fatty liver, some people develop NAFLD without obesity. This suggests that there are other factors.
- genetic influences
- older age
- certain medications, such as steroids, and tamoxifen for cancer treatment
- rapid weight loss
- infections, such as hepatitis
- exposure to some toxins
However, research suggests that “excess fat mass remains the most common background condition.”
NAFLD is also the most common form of long-term liver disease in children. A review published in 2016 states that it affects between 10 and 20 percent of pediatric patients and 50 to 80 percent of children with obesity.
The scientists predict:
“Within the next 10 years, it is expected to become the leading cause of liver pathology, liver failure, and indication for liver transplantation in childhood and adolescence in the Western world.”
Around 25 percent of pediatric patients with NASH will go on to develop cirrhosis within 10 years. Among those with obesity, the risk is higher.
Early stage NAFLD does not usually produce symptoms, so diagnosis usually happens because of a routine blood test or because the person has the relevant risk factors.
If the doctor suspects NAFLD, they will feel the abdominal area, to find out if there is any swelling. They will ask about diet and lifestyle and any use of medications, supplements, and alcohol.
If tests suggest that there is damage to the liver or that the liver is swollen, the doctor must rule out other possible conditions, including alcoholic liver disease.
Imaging scans, such as ultrasound, CT, and MRI can show up fat in the liver.
A biopsy can confirm NAFLD, reveal the extent of the damage, and distinguish it from other types of liver problem. The doctor will use a needle to take a small tissue sample from the liver.
There is no medical treatment for fatty liver, but lifestyle choices, such as achieving or maintaining a healthy weight, can reduce the risk and possibly reverse the damage, in the early stages.
Share on PinterestA diet that contains plenty of fresh food can help prevent liver damage.
To reduce the risk of NAFLD, it is best to:
- follow a balanced diet with moderate portions
- eat plenty of fruits and vegetables
- consume both proteins and carbohydrates, but limit fats and sugars
- reduce salt intake
- replace saturated and trans fats with monounsaturated and polyunsaturated fats
The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) recommend the following dietary tips:
- replace trans fats and animal fats with olive oil, flaxseed oil, corn, soybean, and safflower oils
- eat oily fish instead of meat
- avoid foods that are high in simple sugars, such as fructose, found in sweetened drinks, sports drinks, and juices
- eat more foods that are low on the glycemic index (GI), such as fruits, vegetables, and whole grains
- eat fewer high-GI foods, such as white bread and white rice
- avoid alcohol or drink in moderation
Scientists are looking at whether vitamin E may help, but more research is needed. Those who ae considering taking supplements or herbal remedies should always speak to a doctor first.
A healthy diet and regular exercise will reduce the risk of a wide range of conditions, including diabetes and cardiovascular disease.
For most people, a fatty liver does not usually cause serious problems. To some extent, the liver can repair itself, so switching to a healthy lifestyle will help.
Researchers warn that NAFLD is on the increase, and if obesity continues to rise, it could become “an epidemic.”
Although simple fatty liver is not dangerous, without preventive action, some people will go on to develop NASH, and between 10 and 25 percent of adults with NASH will go on to develop cirrhosis within 10 years.
In the U.S., fatty liver disease is the third cause of liver transplant, and it is on the rise.
In addition, NAFLD is linked to CVD, CKD, and other conditions. Whether or not these can be reversed, even if the liver recovers, is not clear.
The best way to treat and prevent it is through healthful lifestyle choices, with a varied and balanced diet and regular exercise.
Gamma-Glutamyl Transferase (GGT) – Understand the Test & Your Results
Sources Used in Current Review
2019 review performed by Balu K Chacko, PhD, NRCC, University of Alabama at Birmingham.
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Gerald Koenig and Stephanie Seneff. Gamma-Glutamyltransferase: A Predictive Biomarker of Cellular Antioxidant Inadequacy and Disease Risk. Dis Markers. 2015; 2015: 818570. Available online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4620378/. Accessed July 2019.
Low Gamma-GT Familial Intrahepatic Cholestasis. Rare Disease Database (National Organization for Rare Diseases, NORD). Available online at https://rarediseases.org/rare-diseases/low-gamma-gt-familial-intrahepatic-cholestasis/. Accessed July 2019.
Katarzyna Kowalska, Milena Ściskalska, Anna Bizoń, Mariola Śliwińska-Mossoń, Halina Milnerowicz. Influence of oral contraceptives on lipid profile and paraoxonase and commonly hepatic enzymes activities. J Clin Lab Anal. 2018 Jan; 32(1): e22194. Published online 2017 Mar 9. doi: 10.1002/jcla.22194. Accessed July 2019.
Falaq Naz, Smita Jyoti, Rahul, Nishat Akhtar, Yasir Hasan Siddique. Effect of Oral Contraceptive Pills on the Blood Serum Enzymes and DNA Damage in Lymphocytes Among Users. Ind J Clin Biochem (July-Sept 2016) 31(3):294–301. Available online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4910851/. 11. Accessed July 2019.
Kazemi-Shirazi L1, Endler G, Winkler S, Schickbauer T, Wagner O, Marsik C. Gamma glutamyltransferase and long-term survival: is it just the liver? Clin Chem. 2007;53(5):940-6. Available online at https://www.ncbi.nlm.nih.gov/pubmed/17384006. Accessed July 2019.
Jenny HDA, et al. The association of alcohol intake with gamma-glutamyl transferase (GGT) levels: evidence for correlated genetic effects. Drug Alcohol Depend. 2014 Jan 1; 134: 99–105. Published online 2013 Sep 27. doi: 10.1016/j.drugalcdep. 2013.09.016. Accessed November 2019.
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Johnston, D (April 15, 1999). Special Considerations in Interpreting Liver Function Tests. American Family Physician: American Academy of Family Physicians. Available online at http://www.aafp.org/afp/990415ap/2223.html.
Riley, T (November 1, 2001). Preventive Strategies in Chronic Liver Disease: Part I. Alcohol, Vaccines, Toxic Medications and Supplements, Diet and Exercise. American Family Physician: American Academy of Family Physicians. Available online at http://www.aafp.org/afp/20011101/1555.html.
British Liver Trust Information Service (Last update September, 10 2001). Cirrhosis. British Liver Trust. Available online at http://www.britishlivertrust.org.uk/publications/cirrhosis.html.
MEDLINEplus (October 3, 2001). Medical Encyclopedia: ESR. U.S. National Library of Medicine, Bethesda, MD. MEdlinePlus. Available online at http://www.nlm.nih.gov/medlineplus/ency/article/003638.htm.
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Dufour DR, et al. Diagnosis and monitoring of hepatic injury – I. Characteristics of laboratory tests. Clin Chem 2000; 46:2027-2049.
Tietz Textbook of Clinical Chemistry and Molecular Diagnostics. Burtis CA, Ashwood ER and Bruns DE, eds. 4th ed. St. Louis, Missouri: Elsevier Saunders; 2006 Pg 613.
Pagana K, Pagana T. Mosby’s Manual of Diagnostic and Laboratory Tests. 3rd Edition, St. Louis: Mosby Elsevier; 2006, Pp. 259-260.
Clarke, W. and Dufour, D. R., Editors (2006). Contemporary Practice in Clinical Chemistry. AACC Press, Washington, DC, Pg. 271.
Carey, W (January 1, 2009). Approach to the Patient with Liver Disease: A Guide to Commonly Used Liver Tests, Cleveland Clinic. Available online at http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/hepatology/guide-to-common-liver-tests/. Accessed September 2009.
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(2000) Dufour, DR et al. National Academy of Clinical Biochemistry Standards of Laboratory Practice: Laboratory Guidelines for Screening, Diagnosis and Monitoring of Hepatic Injury. Available online at http://www.aacc.org/SiteCollectionDocuments/NACB/LMPG/hepatic/hepatic_combined.pdf#page=3.
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Gamma-glutamyl transpeptidase. (Updated Jan. 21, 2013.) MedlinePlus Medical Encyclopedia. Available online at http://www.nlm.nih.gov/medlineplus/ency/article/003458.htm. Accessed September 2013.
Kim, KM et al. (Dec. 2012) Serum gamma-glutamyltransferase as a risk factor for general cardiovascular disease prediction in Koreans. National Center for Biotechnology Information PubMed database. Available online at http://www.ncbi.nlm.nih.gov/pubmed/23138005. Accessed September 2013.
Gamma-glutamyltransferase level and risk of hypertension: a systematic review and meta-analysis. PLOS. Available online through http://www.plosone.org at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0048878. Accessed September 2013.
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Liver Disease Testing Procedure | Stanford Health Care
What to Expect: Liver Disease Testing
If you are in the early stages of liver disease, your doctor may use a simple blood test to learn more about the health of your liver and possible causes for your symptoms.
Blood tests include:
- Liver function panel (liver panel)
- Liver enzyme tests
- Antibody tests
If you have been fighting liver disease for six months or more (chronic liver disease), imaging tests help us detect and measure liver damage and other complications, such as liver cancer.
Imaging tests include:
Liver function panel (liver panel)
Using a sample of your blood, we run a number of tests (liver panel) to learn more about the general health of your liver.
If your results are abnormal, we may perform more specialized tests:
- Bilirubin test: Bilirubin is the waste product of broken down red blood cells. Having too much bilirubin exposes your liver to toxins that eventually cause damage.
- Albumin test: Albumin, a blood protein made by your liver, helps your blood carry out many vital functions. Low levels of albumin are a sign of liver disease.
- Prothrombin time test: A measure of how quickly your blood clots. Slow clotting is a sign that your liver is not healthy.
Liver enzyme tests
Liver enzyme tests tell us about possible causes for inflammation and liver damage. Liver enzymes are special proteins in the cells of your liver that help you break down food and remove toxins. Having high levels of enzymes, such as alanine aminotransferase (ALT) and aspartate aminotransferase (AST), in your blood is a sign that your liver is in trouble.
Antibodies are proteins in your blood that help fight certain diseases, such as hepatitis B and hepatitis C. Because your immune system produces a unique set of antibodies in response to the presence of each disease, testing positive for hepatitis B or C antibodies helps confirm your diagnosis.
Computed tomography (CT) Scan
With the help of a special dye, a CT scan uses X-rays and sophisticated computer technology to produce image slices (cross-sectional views) of your liver. In addition to minimizing exposure to radiation, CT scans show important details about organ structures, such as the health of blood vessels within your liver.
We offer alternative testing, such as special ultrasounds, if you have chronic liver disease and cannot tolerate the dye we use in CT scans.
High-frequency sound waves and a computer create detailed images of blood vessels, tissues, and organs.
We use ultrasound tests to:
- Examine the structure of your liver and identify possible damage (cirrhosis)
- Rule out problems with other abdominal organs, such as your pancreas
- Look for signs of cancer, such as masses
We offer doppler ultrasound, which uses a special dye, for people who have advanced liver disease and cannot have a CT scan. Doppler is a special type of ultrasound that shows blood flow through your liver.
This magnetic resonance imaging (MRI) test uses a magnetic field and radio waves to help us measure precise levels of liver damage. Also known as Feraheme® MRI or FibroScan®, this advanced technology eliminates the need for a liver biopsy and is only available in prestigious programs, such as Stanford.
Liver Test Interpretation – Approach to the Patient with Liver Disease: A Guide to Commonly Used Liver Tests
Laboratory assessment of the patient with suspected or clinically obvious liver disease is context dependent. For example, the acutely ill jaundiced patient with a history of prolonged alcohol ingestion requires a different laboratory assessment than the well patient in whom one or more standard liver test results are discovered to be abnormal during routine testing. Additionally, the sequence of liver tests depends heavily on the questions being asked. If it is to determine whether this well person whose brother was recently diagnosed with hemochromatosis also has this genetic disease, then a series of tests will be initiated to detect the possibility of iron overload. If it is to determine whether this spouse has been infected with hepatitis B, then blood tests related to hepatitis B will be required. Thus generic algorithms for the evaluation of liver disease need to be considered skeptically.
This chapter is intended to discuss a useful way of thinking about liver tests. It emphasizes limitations of and alternative explanations for isolated abnormalities of common liver test results. It also provides information on the initial screening test to be chosen, their interpretation, and the tests needed to confirm the diagnosis of common liver disorders based on current recommendations. Information in this chapter should be combined with discussions of specific liver diseases in the Disease Management. A final caveat relates to terminology. Tests done in clinical laboratories do not measure any functional capacity of the liver. Hence, the commonly used term liver function test is inaccurate, and the term liver tests is used in this chapter. Guidelines on the interpretation and evaluation of abnormal liver test results have been published.1,2 Useful algorithms are presented that parallel the recommendations in this chapter.
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Isolated Abnormalities in Liver Test Results
A common clinical scenario is the unanticipated discovery of an abnormal liver test result, obtained when a bundle of tests has been done for other reasons. Most clinical laboratories offer bundled blood tests, which often contain all or most of the following:
- Aspartate transaminase (AST, formerly referred to as serum glutamic-oxaloacetic transaminase, SGOT)
- Alanine transaminase (ALT, formerly called serum glutamic-pyruvic transaminase, SGPT)
- Gamma-glutamyl-transpeptidase (GGTP)
- Alkaline phosphatase
- Lactate dehydrogenase (LDH)
Of these tests only the GGTP is liver specific. An isolated elevation of just one of the other test values should raise suspicion that a source other than the liver is the cause (Table 1). When several liver test results are simultaneously out of the normal range, consideration of non-hepatic sources becomes irrelevant.
Table 1: Nonhepatic Sources of Abnormalities for Select Laboratory Tests
|Bilirubin||Red blood cells (e.g., hemolysis, intra-abdominal bleed, hematoma)|
|AST||Skeletal muscle, cardiac muscle, red blood cells|
|ALT||Skeletal muscle, cardiac muscle, kidneys|
|LDH||Heart, red blood cells (e.g., hemolysis)|
|Alkaline phosphatase||Bone, first trimester placenta, kidneys, intestines|
ALT, alanine aminotransaminase; AST, aspartate transaminase; LDH, lactate dehydrogenase.
Additional note should be made of the GGTP and LDH as liver tests. The GGTP level is too sensitive, frequently elevated when no liver disease is apparent. A GGTP test is useful in only two instances: (1) It confers liver specificity to an elevated alkaline phosphatase level; (2) In aminotransferase level elevations with AST/ALT ratio greater than 2, elevation of GGTP further supports alcoholic liver disease. In addition, it can be used to monitor abstinence from alcohol. An isolated elevation of the GGTP level does not need to be further evaluated unless there are additional clinical risk factors for liver disease.3 The LDH assay is insensitive and nonspecific because LDH is present in tissues throughout the body.
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Evaluation of Liver Disease Based on Enzyme Levels
It is customary and useful to categorize liver diseases into three broad categories: Hepatocellular, in which primary injury is to the hepatocytes; cholestatic, in which primary injury is to the bile ducts; and infiltrative, in which the liver is invaded or replaced by non-hepatic substances, such as neoplasm or amyloid. Although there is a great deal of overlap in liver test result abnormalities seen in these three categories, particularly in cholestatic and infiltrative disorders, an attempt to characterize an otherwise undifferentiated clinical case as hepatocellular, cholestatic, or infiltrative often makes subsequent evaluation faster and more efficient. The AST, ALT, and alkaline phosphatase tests are most useful to make the distinction between hepatocellular and cholestatic disease.
The normal range for aminotransferase levels in most clinical laboratories is much lower than that for the alkaline phosphatase level. Accordingly, when considering levels of elevations, it is necessary to consider them relative to the respective upper limit of normal for each test compared. Consider a patient with an AST level of 120 IU/mL (normal, ≤40 IU/mL) and an alkaline phosphatase of 130 IU/mL (normal, ≤120 IU/mL). This represents a hepatocellular pattern of liver injury because the AST level is three times the upper limit of normal, whereas the alkaline phosphatase level is only marginally higher than its upper limit of normal.
Serum aminotransferase levels—ALT and AST—are two of the most useful measures of liver cell injury, although the AST is less liver specific than is ALT level. Elevations of the AST level may also be seen in acute injury to cardiac or skeletal muscle. Lesser degrees of ALT level elevation may occasionally be seen in skeletal muscle injury or even after vigorous exercise. Thus in clinical practice, it is not uncommon to see elevations of AST, ALT or both in common non-hepatic conditions such as myocardial infarction and rhabdomyolysis. Diseases that primarily affect hepatocytes, such as viral hepatitis, will cause disproportionate elevations of the AST and ALT levels compared with the alkaline phosphatase level. The ratio of AST/ALT is of little benefit in sorting out the cause of liver injury except in acute alcoholic hepatitis, in which the ratio is usually greater than 2.
The current upper limit of serum ALT, though varied among laboratories, is generally around 40 IU/L. However, recent studies have shown that the upper limit threshold of ALT level should be lowered because people who have slightly raised ALT levels that are within the upper limit of normal (35-40 IU/L) are at an increased risk of mortality from liver disease.4 In addition, it has been suggested that gender-specific thresholds be applied because women have slightly lower normal ALT levels than men. One such study conducted in the U.S. identified an ALT upper limit of 29 IU/L for men and 22 IU/L for women.5 In asymptomatic patients with minimal elevations of aminotransferases, it is reasonable to repeat the test in a few weeks to confirm elevation. Common causes of mild increases in AST and ALT levels include non-alcoholic fatty liver disease (NAFLD), hepatitis C, alcoholic fatty liver disease, and medication effect (e.g., due to statins).
Serum alkaline phosphatase comprises a heterogeneous group of enzymes. Hepatic alkaline phosphatase is most densely represented near the canalicular membrane of the hepatocyte. Accordingly, diseases that predominately affect hepatocyte secretion (e.g., obstructive diseases) will be accompanied by elevations of alkaline phosphatase levels. Bile-duct obstruction, primary sclerosing cholangitis, and primary biliary cirrhosis (PBC) are some examples of diseases in which elevated alkaline phosphatase levels are often predominant over transaminase level elevations (Table 2).
Table 2: Category of Liver Disease by Predominant Serum Enzyme Abnormality
|Liver Disease Category
|AST, ALT higher than alkaline phosphatase level||Typical||—||—|
|Alkaline phosphatase higher than AST, ALT levels||—||Typical||—|
|Elevation of alkaline phosphatase with near-normal AST, ALT levels||—||Typical||Typical|
ALT, alanine aminotransaminase; AST, aspartate transaminase.
Infiltrative liver diseases most often result in a pattern of liver test result abnormalities similar to those of cholestatic liver disease. Differentiation often requires liver imaging studies. Liver imaging by ultrasound, computed tomography (CT) or magnetic resonance imaging (MRI) most often identify infiltration of the liver by mass lesions such as tumors. Imaging by cholangiography—endoscopic retrograde cholangiography, transhepatic cholangiography, or magnetic resonance cholangiography—identifies many bile duct lesions that cause cholestatic liver disease. Liver biopsy is often needed to confirm certain infiltrative disorders (e.g., amyloidosis) and microscopic biliary disorders such as PBC.
Bilirubin Level Elevations
Bilirubin is produced by the normal breakdown of pigment-containing proteins, especially hemoglobin from senescent red blood cells and myoglobin from muscle breakdown. Bilirubin released from such sources, tightly albumin bound, is delivered to the liver, where it is efficiently extracted and conjugated by hepatic glucuronidation and sulfation. Conjugated bilirubin is rapidly excreted into bile and removed from the body through the gut. Therefore, the amount of conjugated bilirubin present in serum in healthy subjects is trivial (<10% of measured total bilirubin). An elevated level of conjugated serum bilirubin implies liver disease. Also, it is important to note that only conjugated bilirubin appears in urine (unconjugated bilirubin is albumin bound and water insoluble). The presence of bilirubin in urine almost always implies liver disease.
Many laboratories report only the total bilirubin level, the sum of the conjugated and unconjugated portions. It is sometimes useful to determine the fraction of total serum bilirubin that is unconjugated versus that which is conjugated, usually referred to as fractionation of bilirubin. This is most useful when all the standard liver test results are normal, except the total bilirubin. To make matters more confusing, the conjugated bilirubin is sometimes referred to as the direct-reacting bilirubin and the unconjugated as the indirect-reacting bilirubin (Table 3).
Table 3: Bilirubin Fractions Present in Blood and Urine
|Fraction||In Serum As||Measured As||Present in Urine|
|Conjugated||Unbound||Direct-reacting bilirubin||Yes, when serum bilirubin level is elevated|
Normally, 90% or more of measured serum bilirubin is unconjugated (indirect-reacting). When the total bilirubin level is elevated and fractionation shows that the major portion (≥90%) is unconjugated, liver disease is never the explanation. Instead, the clinician should suspect one of two explanations: Gilbert disease or hemolysis. If the patient is young and healthy, an inherited decrease in the inability to conjugate bilirubin is likely and is referred to as Gilbert syndrome. It is seen in about 5% of the general population and causes only mild hyperbilirubinemia without symptoms. It is not associated with liver disease. Interestingly, fasting and intercurrent illnesses such as influenza often make the level of unconjugated bilirubin even higher in those with Gilbert syndrome. This syndrome is easily diagnosed when all standard liver-test results are normal and 90% or more of the total bilirubin is unconjugated. There is no need for an imaging study or liver biopsy in cases of suspected Gilbert syndrome.
Elevations of the unconjugated bilirubin level when the conjugated bilirubin level remains normal may also indicate an increased load of bilirubin caused by hemolysis. Anemia and an elevated reticulocyte count are usually present in such cases (Table 4).
Table 4: Common Causes of Isolated Bilirubin Elevation
|Cause||Direct-Reacting Bilirubin||Indirect-Reacting Bilirubin||Associated Features|
|Liver disease (many types)||Elevated||Elevated or normal||Liver enzyme levels often elevated|
|Hemolysis||Normal||Elevation represents more than 90% of total bilirubin||Anemia usual; increased reticulocyte count; normal liver enzyme levels (although LDH may be elevated)|
|Gilbert’s syndrome||Normal||Elevation represents more than 90% of total bilirubin (common)||No abnormal liver tests; no anemia; onset in late adolescence; fasting makes bilirubin rise|
LDH, lactate dehydrogenase.
Many clinicians mistakenly interpret elevations of direct-reacting bilirubin to indicate that cholestatic (obstructive) liver disease is present. It is apparent from Table 2 that the serum bilirubin level plays no useful role in categorizing a case as hepatocellular, cholestatic, or infiltrative. The bilirubin level may be normal or elevated in each type of disorder. Viral hepatitis A, a prototypic hepatocellular disease, may frequently be associated with bilirubin levels that are high, whereas PBC, a prototypic cholestatic disorder, is associated with a normal serum bilirubin level except in later stage disease. Serum bilirubin levels should be disregarded when trying to decide whether the liver-test pattern is more suggestive of hepatocellular or cholestatic disease.
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Determination of Specific Liver Disorders
Acute Alcoholic Hepatitis
Acute alcoholic hepatitis may be mild or life threatening. The pattern of liver test abnormality is hepatocellular. The AST is typically in the 100 to 200 IU/L range, even in severe disease, and the ALT level may be normal, even in severe cases. The AST level is higher than the ALT level, and the ratio is greater than 2:1 in 70% of patients. A ratio greater than 3 is strongly indicative of alcoholic hepatitis. An important corollary is that an AST greater than 500 IU/L or an ALT greater than 200 IU/L is not likely to be explained by acute alcoholic hepatitis—even in an alcoholic patient—and should suggest another etiology.6
The degrees of bilirubin level increase and prothrombin time elevation are better indicators of severity of disease. In alcoholic hepatitis, the Maddrey discriminant function (MDF), a disease-specific prognostic score which indicates the severity of liver injury, has been developed. The formula to calculate the score is as follows:
MDF = 4.6 (patient’s prothrombin time − control prothrombin time) + total bilirubin (mg/dL)
Patients who have a score of 32 or greater have an increased risk of death, with a 1-month mortality rate of 30% to 50%.
Viral hepatitis most often produces a hepatocellular pattern of injury (AST and ALT level elevations predominate). Patients who have no symptoms and in whom aminotransferase levels are normal may still be infected. In addition, a great deal of confusion is caused by abnormal viral markers, many of which do not indicate active infection but rather immunity. These concepts are more fully developed elsewhere in the Cleveland Clinic Disease Management.
Hepatitis A virus (HAV) infection is an acute, self-limited disease in most cases, although it may rarely be fatal. Diagnosis is made through the use of antibody tests (anti-HAV). Positive anti-HAV IgM antibody is diagnostic of acute hepatitis A infection and has a very good sensitivity and specificity. The IgM antibodies are usually positive at the time of the onset of symptoms and they remain positive for about 3 to 6 months after, and in some cases as long as 1 year. Anti-HAV immunoglobulin G (IgG) antibodies develop later than anti-HAV immunoglobulin M (IgM) but they persist for many years and offer immunity. Anti-HAV IgG antibodies are also seen following vaccination.
The presence of anti-HAV IgM—irrespective of the presence of anti-HAV IgG—suggests acute infection. The presence of anti-HAV IgG in the absence of IgM suggests previous infection or post-vaccination antibodies.
When an acute hepatitis A panel is ordered, the test result that is obtained from the laboratory must be interpreted with caution before making the diagnosis. This is because the standard screening tests performed by most laboratories measure the level of total anti-HAV antibodies. Total anti-HAV antibody tests will be positive in the presence of either anti-HAV IgG or IgM, as the reagents used in this test will react to both anti-HAV IgG and IgM. Therefore, a positive total anti-HAV antibody test alone does not provide the diagnosis of acute hepatitis A. Selective testing of serum IgM anti-HAV is required to establish such a diagnosis (Table 5).
Table 5: Hepatitis A Antibody Testing In Different Clinical States
|State||Total Anti-HAV (IgG, IgM)||Anti-HAV IgM|
|Acute hepatitis A||Positive||Positive|
|Resolved hepatitis A||Positive||Negative|
HAV, hepatitis A virus; IgG, immunoglobulin G; IgM, immunoglobulin M.
Like hepatitis A, hepatitis B in adults produces hepatocellular enzyme level elevations (AST and ALT predominate). In adults who acquire hepatitis B, the infection almost always clears, but antibodies persist. In a few, the disease does not resolve but becomes chronic. These patients retain serum markers of viral infection. Many blood tests are available for hepatitis B antigenic determinants and their antibodies. It is best to separate testing appropriate for the acute hepatitis situation from testing for chronic liver disease caused by hepatitis B. Only a few tests need to be considered by the generalist to determine the status of a patient with possible hepatitis B. A full discussion of hepatitis B can be seen in the Disease Management chapter on Hepatitis B.
Acute Hepatitis B
Hepatitis B surface antigen (HBsAg) emerges within 2 weeks of exposure but can often be delayed for weeks or months. This antigen is present in the blood for a variable period, usually encompassing the time during which the patient is clinically ill and most likely to seek medical attention. In patients with mild symptoms whose testing may be delayed, the HBsAg level may have already declined. In this case, a second chance to make the diagnosis comes from detection of the IgM antibody directed against the hepatitis B core (HBc) antigen, anti HBc-IgM (Table 6). Similar to the testing for acute hepatitis A, selective testing of serum IgM anti-HBc is required to establish a diagnosis of acute hepatitis B in patients whose HBsAg levels have already declined. The total anti-HBc antibody test will be positive in the presence of either anti-HBc IgG or IgM.
Table 6. Common Hepatitis B Testing Results
|HBsAg||Negative||Immune due to natural infection|
|HBsAg||Negative||Immune due to hepatitis B vaccination|
|HBsAg||Negative||Interpretation unclear 4 possibilities:|
|Anti-HBc||Positive||1. Resolved infection (most common)|
|Anti-HBs||Negative||2. False positive|
|3. “Low level” chronic infection|
|4. Resolving acute infection|
From: Interpretation of hepatitis B serologic test results. Centers for Disease Control and Prevention website. www.cdc.gov. Accessed June 27, 2013.
In acute hepatitis B, medical attention is not sought early. In such cases the HBsAg may have already disappeared. The anti-HBs will not yet have emerged. Thus the sole viral marker may be anti-HBc. This same serologic pattern may be seen years after infection when the titer of anti-HBs is low. Sorting out the difference between late resolved hepatitis B and the period in acute hepatitis B described above can be achieved by testing for anti-HBc IgM which will be positive during this so-called “window period” of acute hepatitis B.
Chronic Hepatitis B
Chronic hepatitis B is characterized by persistence of HBsAg for a period longer than 6 months with positive anti-HBc (IgG), and negative anti-HBs. An additional antigen-antibody system plays a role in patients with chronic hepatitis B and requires mention: the hepatitis B e antigen (HBeAg) and its antibody (anti-HBe). HBeAg positivity in chronic hepatitis B usually indicates active viral replication and significant liver injury. In time, HBeAg may be lost, replaced by its antibody, anti-HBe. This transformation is often associated with lower level infection (less viral replication) or HBV DNA, lower AST and ALT values, and less (or no) hepatic inflammation.
Reactivation Hepatitis B
Hepatitis B reactivation is a sudden increase in hepatitis B virus (HBV) replication or the reappearance of active inflammatory disease of the liver in a patient with previously documented resolved HBV, or with the inactive HBsAg carrier state. Reactivation is usually triggered by immunosuppression in the host, which can occur following the use of chemotherapeutic agents for malignancy and following therapy for autoimmune diseases or organ transplantation.
Reactivation can also occur spontaneously. The extent of clinical manifestation from reactivation HBV can vary from a transient, clinically silent disease to severe or acute liver failure. A chronic infectious state can also be seen following HBV reactivation. Diagnosis of HBV reactivation depends on the HBV disease state before activation. In a patient with resolved infection (negative HBsAg and positive anti-HBs), reactivation is indicated by the decline in anti-HBs and the reappearance of HBsAg. In patients with quiescent HBV with positive HBsAg, reactivation is diagnosed by a rise in the serum HBV DNA (>1 log10 IU/mL) or a rise in the serum ALT levels (>3 times baseline). Reappearance of HBeAg in a patient with previous negative HBeAg also indicates HBV reactivation.
Role of HBV DNA Assays, HBV Genotypes and Liver Biopsy in Chronic Hepatitis B
HBV DNA level plays several important roles in chronic hepatitis B. It is the most important factor for predicting the progression to cirrhosis, helps to determine the need for treatment in HBeAg negative patients, and also plays a crucial role in estimating the response to treatment. Up to 8 HBV genotypes, labeled from A to H, have been identified. Recent studies have shown that some genotypes are associated with early HBeAg seroconversion, less progression to cirrhosis and hepatocellular carcinoma, and may also predict the response to treatment with interferon. These concepts and exceptions are discussed more fully in the Hepatitis B chapter. A clinical practice guideline on viral hepatitis B has provided additional information on laboratory testing in various contexts of hepatitis B infection.7
Resolved Hepatitis B and Immunization Status
As indicated in Table 6, an individual with resolved hepatitis B infection almost always has anti-HBc and anti-HBs. An individual successfully immunized against hepatitis B expresses only anti-HBs. Confusion may occasionally arise in the interpretation of hepatitis B tests in a patient who has recovered from hepatitis B many years ago and who has a low or absent level of measurable anti-HBc.
Because hepatitis C infection usually produces no symptoms, or only mild, nonspecific, flu-like symptoms, it is infrequently diagnosed in the acute phase. The virus clears spontaneously in about 15% of infected patients. Although generally helpful for the diagnosis of chronic infection, antibody tests are often not useful for diagnosis of acute hepatitis C virus (HCV) infection because the emergence of the antibody is delayed for several months after infection. To test for possible acute HCV infection, measurement of HCV RNA should be performed (Table 7). See the Disease Management chapter on Hepatitis C for further details.
Table 7: Hepatitis C Testing
|Test||Source||When To Order|
|Anti-HCV EIA||Patient immune system||Suspect HCV|
|HCV RNA PCR||HCV virus||Confirm current infection – If anti-HCV positive
Or if acute HCV suspected
Or in immunocompromised HCV suspect
|HCV genotype||HCV virus||If HCV RNA positive and treatment contemplated|
|IL28B||Patient DNA||If genotype I HCV and treatment contemplated|
HCV, hepatitis C virus; EIA, enzyme immunoassay; PCR, polymerase chain reaction.
To test for chronic HCV infection, immunologic response to infection (antibodies) and viral assays are used. The most commonly used anti-HCV antibody test is an enzyme immunoassay with a specificity of greater than 99%. An individual with risk factors, elevated liver tests, and a positive anti-HCV has an overwhelming chance of HCV infection.
False-positive anti-HCV antibodies are occasionally encountered. Confirmation of chronic hepatitis C infection is obtained by the direct measurement of viral products in serum (HCV RNA). HCV RNA in serum definitively establishes the presence of HCV infection and is recommended in all patients with a positive anti-HCV test. Some clinicians have questioned whether the initial screening test for HCV should be an HCV RNA test or an antibody test. Currently, however, because of cost considerations, the initial test for HCV remains an anti-HCV antibody test.
False-negative anti-HCV tests can occur in two clinical contexts: in a patient with a recent infection, in an immunocompromised individual, or an individual receiving hemodialysis. HCV RNA testing is recommended in patients with negative anti-HCV antibody tests but who have liver disease of unknown etiology and are also immunocompromised.8 In addition, all potential organ donors should be tested for HCV RNA. Figure 1 gives a simplified diagnostic algorithm for hepatitis C.
Once the presence of HCV is established, the genotype should be determined. There are 6 major HCV genotypes (1-6). Genotyping continues to gain importance for treatment determinations. This is discussed more fully elsewhere in the Hepatitis C chapter.
Role of IL28B Genotype in Hepatitis C
Current guidelines do not routinely recommend interleukin 28B (IL28B) genotype testing.8 Nevertheless, it is commonly ordered to obtain information about the probability of treatment response and the duration of treatment. We recommend one-time testing of IL28B in every patient who is infected with genotype-1 hepatitis C who is also a candidate for treatment.
IL28 is a cytokine that plays an important role in the defense against viral infection. It belongs to the IL10 interferon family and, in response to a virus, helps to upregulate the inflammatory potential and the innate immunity. IL28 has two isoforms, namely IL28A and IL28B. The gene for IL28B resides on chromosome 19. Recent studies have identified a single nucleotide pleomorphism near the IL28B gene that can predict the response to treatment in hepatitis C. Three genotypes exist as a result of the nucleotide pleomorphism. They are the CC, CT, and TT genotypes. Among patients who spontaneously clear HCV virus, the CC genotype has been shown to be present more than twice as frequently than the other genotypes. In addition, patients with the CC genotype also show a much better response to treatment with anti-viral therapy as compared with the CT or TT genotype. Those with TT have the least response to treatment. This pattern has been observed among all ethnic groups.
Iron and Copper Overload Diseases
Diseases characterized by iron overload and copper overload are discussed in detail in the Disease Management (Inherited Metabolic Liver Diseases: Hemochromatosis, Wilson Disease). A practice guideline has been published.9
Excess iron may accumulate in the liver and other organs for a variety of reasons. Some individuals have a genetic disorder while others may accumulate too much iron for other reasons. Among the genetic iron-overload conditions, the most common in individuals of Northern European ancestry is related to an autosomal recessive disorder, hereditary hemochromatosis. Before ordering tests it is important to be clear about what question is being asked. Most of the time the question is: Does my patient have iron overload?
This question should be entertained in the following situations:
- Any adult with liver disease, especially men and post-menopausal women
- Patients with symptoms suggestive of or having a family history of HH
The initial evaluation for iron overload includes measurement of serum ferritin, iron, iron-binding capacity, and transferrin saturation levels. Transferrin saturation less than 45%, in addition to normal serum ferritin level usually rules out iron overload (negative predictive value of 97%), and no further testing is necessary. Transferrin saturation greater than 45% and/or a serum ferritin above normal level warrants further investigation.9 However, these thresholds are low, and most patients who exceed these limits will not prove to have iron overload as explained below.
Limitations of Serum-Based Tests of Iron Overload
Because both iron and ferritin are stored in liver cells, any condition that results in hepatocyte injury and release of intracellular contents into the blood will falsely raise iron, transferrin saturation, and ferritin levels. Therefore, in acute hepatic injury these tests will falsely suggest iron overload. Acute inflammation outside the liver may also falsely elevate the results of serum-based iron tests. Tests of serum ferritin levels, iron, iron-binding capacity, and percentage saturation determined in the setting of markedly elevated aminotransferase levels (AST and ALT), such as those seen in acute viral hepatitis or massive hepatic necrosis, will be identical to those seen in hemochromatosis. Iron studies cannot be interpreted in the face of major elevations of transaminase levels.
Normal serum iron studies do not preclude future iron overload in the genetically susceptible individual. In a young patient with this condition who has not yet had enough time to accumulate iron (especially the premenopausal woman), screening tests for iron overload may be normal, even though the individual is at risk for the subsequent development of iron overload.
When iron overload is found or suspected, the question may become:
Does my patient have hereditary hemochromatosis?
This question should be entertained in:
- Any patient with elevated iron/total iron-binding capacity ferritin values
- Those with a family history of liver disease or of hemochromatosis
It has been known for years that many cases of hemochromatosis are inherited as an autosomal recessive trait. In many cases, a defective gene called the HFE gene is implicated. The presence of this inherited gene results in the production of a protein in which a tyrosine amino acid rather than a cysteine amino acid is present at position 282 of the HFE protein. A second missense gene that results in an aspartic acid (instead of histidine) at position 63 of the same protein may increase iron absorption in some patients. The abnormalities are called C282Y and H63D mutations respectively. Most individuals of Northern European descent with hereditary hemochromatosis usually have two abnormal genes (homozygosity). Most often, two C282Y genes are present, but occasionally a compound heterozygote (C282Y-H63D) will also have excess iron. Homozygosity for H63D does not usually result in excess iron absorption (Table 8).
Table 8: Guidance for the Likelihood of Iron Accumulation with Various HFE Patterns
|HFE Finding||Likelihood of Iron Overload|
|Wild type/wild type (no abnormal genes)||Nil|
|C282Y/C282Y (C282Y homozygote)||High|
|H63D/H63D (H63D homozygote)||Low|
|C282Y/H63D (compound heterozygote)||Moderate|
Confirming a Diagnosis of Hemochromatosis and the Role of Liver Biopsy
Homozygosity for C282Y and compound heterozygosity for C282Y/H63D are diagnostic of HH and a liver biopsy with hepatic iron index (HII) estimation, which was previously the criteria for diagnosis, is no longer needed to confirm the diagnosis of HH in these patients. In addition, HFE gene mutation testing is indicated in all first-degree relatives of patients with hemochromatosis.9 However, it must be remembered that many individuals have iron overload with normal HFE protein. Pre-menopausal women with C282Y homozygosity most often have no iron accumulation. Finally, there is incomplete penetrance of iron overload in many C282Y homozygotes. In other words, expression of disease may not occur despite having the genetic susceptibility.
HFE gene mutation analysis does not establish either the presence or the degree of liver fibrosis or cirrhosis. Studies have shown that patients with serum ferritin less than 1,000 ng/mL are less likely to have cirrhosis in HH.10 A liver biopsy is thus indicated in patients with elevated ferritin greater than 1,000 ng/mL or having abnormal liver enzymes. This serves two purposes, determining fibrosis and providing an assessment of iron stores. Because there is an age-dependent increase in hepatic iron in normal individuals, it is necessary to create an index that takes this into account. HII is calculated as follows:
HII = hepatic iron concentration(mcmol/g dryweight) ÷ patient age(years)
HII less than 1.9 is normal; values greater than 1.9 are seen in hemochromatosis.9 A caveat to this would be in cirrhotic livers, which have the tendency to rapidly accumulate iron in liver disease of other etiologies and cause elevation of HII to a level greater than 1.9. Newer techniques, such as the HIC estimation by proton transverse relaxation time determined by MRI, could be an alternative to liver biopsy, and studies have shown good correlation between the tests. It must be remembered that bone marrow iron stores are not adequate to assess total body iron stores. Cases of hemochromatosis with absent stainable bone marrow iron have been reported.
Although copper may accumulate to moderate excess in the liver in any chronic cholestatic liver condition, it does not appear to be injurious in these conditions. Wilson disease is the main disease in which pathologic copper deposition results in serious liver injury, cirrhosis, and death. In Wilson disease, copper also accumulates in the basal ganglia of the brain, where it produces a wide gamut of neurologic abnormalities. Patients may present with liver disease, brain disease, or both. This disorder is discussed in more detail in the Disease Management (Inherited Metabolic Liver Diseases: Wilson’s Disease).
Wilson disease is rare. Untreated, it is usually fatal before the patient is aged 40 years. Therefore, it is most appropriate to consider this potential cause in a child or young adult with otherwise unexplained liver disease. However, a diagnosis of Wilson disease should not be excluded based on age alone. Laboratory diagnosis is most often based on the finding of a low ceruloplasmin level. Serum ceruloplasmin level of less than 5 mg/dL strongly suggests Wilson disease while any subnormal level warrants further evaluation. Most acute and chronic liver diseases cause the ceruloplasmin level to elevate. There are a few exceptions to this. A patient with acute fulminant liver failure of any sort may no longer have a liver capable of ceruloplasmin synthesis, so that patient may have a low serum level. Similarly, the patient with terminal end-stage liver disease may have a falling ceruloplasmin level. Finally, a few individuals have congenital hypoceruloplasminemia without copper accumulation and are healthy. At the same time, it must also be remembered that a normal serum ceruloplasmin level does not exclude Wilson disease.
In patients in whom Wilson disease is suspected, in addition to serum ceruloplasmin, 24-hour urinary copper levels and slit lamp examination to look for Kayser-Fleischer (KF) rings should be obtained. A serum ceruloplasmin level less than 20 mg/dL, 24-hour urine copper greater than 40 mcg, and the presence of KF rings confirms the diagnosis of Wilson disease. No further testing such as a liver biopsy is needed in this setting.11
Copper is present in the serum in two forms: copper that is bound to ceruloplasmin, and free copper or the non-ceruloplasmin bound copper. The total serum copper level is the sum of the levels of these two forms of copper and is usually low in those with Wilson disease. This is partly explained by the decrease in the ceruloplasmin bound copper level that results from a reduction in the ceruloplasmin level in Wilson disease. However, the serum free copper level is typically elevated to ≤25 mcg/dL in patients with Wilson disease and may be approximated as follows:
Serum free copper level = Total serum copper level (ug/dl)l − (3 x serum ceruloplasmin level (mg/dL))
A practical algorithm on the diagnostic tests for Wilson disease in shown in Table 9.11
Table 9: Diagnostic Tests for Wilson Disease
|Level 1 Tests||Level 2 Tests||Level 3 Tests|
|Low serum ceruloplasmin level (<20 mg/dL)||Liver histopathology and stainable copper||Ultrastructural study of hepatocytes|
|Kayser-Fleischer rings||Liver copper concentration (>250 µg/g dry weight)||Mutational gene analysis for Wilson disease|
|Raised serum-free copper level (non-ceruloplasmin-bound) (>25 µg/dL)||Incorporation of radiocopper into ceruloplasmin|
|24-hr urinary copper (>100 µg/24 hr)|
Autoimmune Liver Diseases
The two most common forms of autoimmune liver disease are autoimmune chronic hepatitis and PBC. Ninety percent of those with each disorder are women. Autoimmune hepatitis (AIH) is characterized by very high serum aminotransferase (ALT and AST) levels, whereas PBC is a cholestatic disorder with predominant elevations of the alkaline phosphatase level. Each is associated with autoantibodies in the serum. The treatment for each is different, so accurate diagnosis is essential. Table 10 contrasts the laboratory findings of these two autoimmune liver disorders.
Table 10: Contrasting Features of Two Autoimmune Liver Diseases
|Feature||Autoimmune Chronic Hepatitis||Primary Biliary Cirrhosis|
|AST, ALT||7-10 times upper limit of normal (ULN)||1-3 times ULN|
|Alkaline phosphatase||1-3 times ULN||2-10 times ULN|
|Anti-smooth muscle antibody positive||90% (usually high titer)||10%-20% (usually low titer)|
|Anti-mitochondrial antibody positive||10%-20% (usually low titer)||90%-100% (usually high titer)|
|Liver-kidney microsomal antibody positive||Positive in some cases in which smooth muscle antibody is negative (rare in North America)||Negative|
ALT, alanine aminotransaminase; AST, aspartate transaminase.
Interpretation of autoimmune markers in a patient with liver disease is highly context-dependent. Autoantibodies are common in low titer in a number of acute and chronic liver conditions, such as viral hepatitis. Therefore, the finding of autoantibodies in low titer is not sufficient evidence with which to make a diagnosis of autoimmune chronic hepatitis or PBC. At the same time, low titers do not exclude the diagnosis.
AIH should be rapidly recognized by its propensity to occur in women (90%) and to be associated with high transaminase levels (200 IU/mL or higher). In this disease, elevations of the gamma globulins (especially IgG) are pronounced. A myriad of autoimmune markers may be positive in autoimmune chronic hepatitis, but only a few serological markers have to be assessed: anti-smooth muscle antibody, antinuclear antibody, liver-kidney microsomal antibody and anti-liver cytosol type 1 antibody. High titers of antibodies are suggestive of but on their own they do not establish a diagnosis of AIH.
The diagnosis of AIH can be difficult at times and various factors need to be taken into account. Clinical criteria are usually sufficient to make a diagnosis of or to exclude AIH. Scoring systems have been developed to assist in establishing a diagnosis of AIH.12,13 Exclusion of other liver diseases should be undertaken as part of the work up. A liver biopsy at presentation is recommended to establish the diagnosis of AIH and to make treatment decisions.14
Primary Biliary Cirrhosis
PBC is an autoimmune liver disease that characteristically involves the intrahepatic small bile ducts. In this condition, serum-based liver tests reveal a predominant elevation of the alkaline phosphatase level. It is associated with the elevation of an autoantibody in high titer known as the anti-mitochondrial antibody (AMA). It has a high sensitivity and a very high specificity. It is reported to be seen in less than 1% of normal people. However AMA has been shown to be present in increased frequency in relatives of patients with PBC. One study showed that the frequency of positive AMA among first-degree relatives of patients with PBC was 13% as compared with 1% in controls.15 Though positive AMA antibodies may suggest susceptibility to development of PBC, they, on their own even in high titers, do not establish a diagnosis of PBC. Ultrasound or other imaging techniques are necessary in all patients to exclude bile duct obstruction as the cause of cholestasis. Presence of predominant alkaline phosphatase elevation and positive AMA antibody establishes the diagnosis of PBC.16 Liver biopsy is indicated if the AMA is negative or is in low titers and if associated AIH or NAFLD is suspected. Occasionally, a patient may have features of both autoimmune chronic hepatitis and PBC known as AIH/PBC overlap syndrome. PBC is discussed more in detail elsewhere in the Disease Management (“Primary Biliary Cirrhosis, Primary Sclerosing Cholangitis, and Other Cholestatic Liver Diseases”).
Non-Alcoholic Fatty Liver Disease
NAFLD is the most common cause of mildly elevated liver enzymes. Please see the chapter on Non-Alcoholic Fatty Liver Disease in Disease Management. NAFLD is defined as the accumulation of fat in the liver in the absence of conditions that cause secondary fat accumulation such as alcoholic hepatitis, medications, metabolic disorders or viral hepatitis.17 Two types of NAFLD have been described, non-alcoholic fatty liver and non-alcoholic steatohepatitis. The latter has evidence of hepatocellular injury in addition to fat accumulation. Patients with NAFLD are non-alcoholic, usually obese, and have a high BMI.
Liver tests are unreliable guides to the presence or absence of fatty liver disease. When elevated, enzymes show hepatocellular pattern, often with an AST/ALT ratio of less than 1. However, they can be normal. Therefore, liver tests are not useful to make a diagnosis of NAFLD. A history of significant alcohol intake can reliably distinguish between alcoholic fatty liver disease and NAFLD. Imaging is performed to demonstrate the presence of fat in the liver. Liver biopsy is indicated if competing etiologies cannot be ruled out, if a co-existing liver disease is suspected, and for patients at risk of developing cirrhosis.17
A scoring system has been developed to identify patients with liver fibrosis in NAFLD.18 This scoring system comprises of six variables namely: age, hyperglycemia, body mass index, platelet count, albumin, and AST/ALT ratio. The system has been shown to distinguish patients with NAFLD and with or without advanced fibrosis accurately. Certain biomarkers such as serum CK18 have been shown to predict the presence of hepatocellular injury in NAFLD, but further studies are needed to establish their utility.
Noninvasive Tests for Liver Fibrosis and Cirrhosis
Liver biopsy is the gold standard for determining the stage of liver fibrosis and cirrhosis. However, it is invasive and can cause significant complications and sampling error, the latter due to the non-uniform distribution of fibrosis in the liver. In recent years, a number of noninvasive tests have been developed and are being studied to assess liver fibrosis and cirrhosis. Among these, the most widely studied and promising noninvasive tests are hepatic elastography and the serologic markers of fibrosis. Serologic markers can be further divided into direct markers and indirect markers. Direct serologic markers are those that are associated with the deposition of matrix and include procollagen type III amino-terminal peptide (P3NP), type I and IV collagens and matrix metalloproteinases among others.19 P3NP is found to be the most promising among these markers. It is elevated in both acute and chronic liver disease. Studies have also shown that the serum levels of P3NP reflect the degree of fibrosis in chronic liver disease. However, the test is currently not readily available in commercial laboratories and has not yet been validated for use.
Hepatic elastography is a noninvasive imaging technique used to determine the degree of fibrosis of the liver. Most frequently, ultrasound-based elastrography is performed. It uses a device called Fibroscan which transmits low-frequency waves into the liver. The waves’ velocities are then recorded and are shown to correlate with the liver stiffness. It can be performed either by an ultrasound or MRI. Studies have shown that ultrasound elastography has excellent diagnostic accuracy to diagnosing cirrhosis but does not perform as well to assess fibrosis. Magnetic resonance elastography has been shown to be the most promising noninvasive test as studies have shown that it can assess both the degree of fibrosis in addition to diagnosing cirrhosis.20 However, its use may be limited by its high cost. In addition, these tests are not yet FDA-approved to be used in the United States. Therefore, liver biopsy still remains the most important tool in the assessment of liver fibrosis and cirrhosis, though the need for it may be significantly decreased in the future with the further development and validation of noninvasive tests.
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Laboratory assessment of the patient with suspected or clinically obvious liver disease is context dependent and has to be individualized. It is useful to categorize liver diseases into three broad categories: hepatocellular, cholestatic, and infiltrative. Once the liver disease has been categorized, following appropriate diagnostic algorithms driven by a good history and physical examination are the easiest and the most reliable ways to obtain the correct diagnosis.
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- American Gastroenterological Association. Medical position statement: evaluation of liver chemistry tests. Gastroenterology 2002; 123:1364–1366.
- Green RM, Flamm S. AGA technical review on the evaluation of liver chemistry tests. Gastroenterology 2002; 123:1367–1384.
- Carey WD. How should a patient with an isolated GGT elevation be evaluated? Cleve Clin J Med 2000; 67:315–316.
- Kim HC, Nam CM, Jee SH, Han KH, Oh DK, Suh I. Normal serum aminotransferase concentration and risk of mortality from liver diseases: prospective cohort study [published online ahead of print March 17, 2004]. BMJ 2004; 328:983. doi:10.1136/bmj.38050.593634.63.
- Ruhl CE, Everhart JE. Upper limits of normal for alanine aminotransferase activity in the United States population. Hepatology 2012; 55:447–454.
- O’Shea R, Dasarathy S, McCullough AJ; Practice Guideline Committee of the American Association for the Study of Liver Diseases; Practice Parameters Committee of the American College of Gastroenterology. Alcoholic liver disease. Hepatology 2010; 51:307–328.
- Lok AS, McMahon BJ. Chronic hepatitis B: update 2009. Hepatology 2009; 50:661–662.
- Ghany MG, Nelson DR, Strader DB, Thomas DL, Seeff LB; American Association for Study of Liver Diseases. An update on treatment of genotype 1 chronic hepatitis C virus infection: 2011 practice guideline by the American Association for the Study of Liver Diseases [published online ahead of print September 26, 2011]. Hepatology 2011; 54:1433–1444. doi:10.1002/hep.24641.
- Bacon BR, Adams PC, Kowdley KV, Powell LW, Tavill AS; American Association for the Study of Liver Diseases. Diagnosis and management of hemochromatosis: 2011 practice guideline by the American Association for the Study of Liver Diseases. Hepatology 2011; 54:328–343.
- Morrison ED, Brandhagen DJ, Phatak PD, et al. Serum ferritin level predicts advanced hepatic fibrosis among U.S. patients with phenotypic hemochromatosis. Ann Intern Med 2003; 138:627–633.
- Roberts EA, Schilsky ML; American Association for Study of Liver Diseases (AASLD). Diagnosis and treatment of Wilson disease: an update. Hepatology 2008; 47:2089–2111.
- Alvarez F, Berg PA, Bianchi FB, et al. International Autoimmune Hepatitis Group Report: review of criteria for diagnosis of autoimmune hepatitis. J Hepatol 1999; 31:929–938.
- Hennes EM, Zeniya M, Czaja AJ, et al; International Autoimmune Hepatitis Group. Simplified criteria for the diagnosis of autoimmune hepatitis. Hepatology 2008; 48:169–176.
- Manns MP, Czaja AJ, Gorham JD, et al; American Association for the Study of Liver Diseases. Diagnosis and management of autoimmune hepatitis. Hepatology 2010; 51:2193–2213.
- Lazaridis KN, Juran BD, Boe GM, et al. Increased prevalence of antimitochondrial antibodies in first-degree relatives of patients with primary biliary cirrhosis. Hepatology 2007; 46:785–792.
- Lindor K, Gershwin ME, Poupon R, Kaplan M, Bergasa NV, Heathcote EJ; American Association for Study of Liver Diseases. Primary biliary cirrhosis. Hepatology 2009; 50:291–308.
- Chalasani N, Younossi Z, Lavine JE, et al; American Association for the Study of Liver Diseases; American College of Gastroenterology; American Gastroenterological Association. The diagnosis and management of non-alcoholic fatty liver disease: practice guideline by the American Association for the Study of Liver Diseases, American College of Gastroenterology, and the American Gastroenterological Association [published correction appears in Am J Gastroenterol 2012; 107:1598]. Am J Gastroenterol 2012; 107:811–826.
- Angulo P, Hui JM, Marchesini G, et al. The NAFLD fibrosis score: a noninvasive system that identifies liver fibrosis in patients with NAFLD. Hepatology 2007; 45:846–854.
- Carey E, Carey WD. Noninvasive tests for liver disease, fibrosis, and cirrhosis: is liver biopsy obsolete? Cleve Clin J Med 2010; 77:519–527.
- Godfrey EM, Patterson AJ, Priest AN, et al. A comparison of MR elastography and 31P MR spectroscopy with histological staging of liver fibrosis [published online ahead of print July 1, 2012]. Eur Radiol 2012; 22:2790–2797. doi:10.1007/s003330-012-2527-x.
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What Does it Mean if a Dog has Elevated Liver Values? • MSPCA-Angell
By Mara Ratnofsky, DVM
The liver is an amazing organ which carries out over 500 life-sustaining functions. It processes all of the blood leaving the gastrointestinal tract – breaking down toxins, converting medications into forms that can be better used by the body, and creating nutrients. The liver stores energy and iron for future use by the body, helps regulate blood clotting, and clears old red blood cells from circulation. The liver secretes its waste products in the form of bile, a substance which also aids in the digestion of fats.
Your veterinarian may recommend a blood test to check your dog’s liver values. This may be part of a routine screen to get a more complete picture of your dog’s overall health, or your vet may have concerns about your dog’s liver function. Poor appetite, vomiting, lethargy, increased drinking and urination, yellow discoloration of the eyes or skin, seizures, and fluid build-up in the abdomen can all be signs of liver disease.
Below is a breakdown of what your vet is evaluating when he or she looks at “liver values.”
1) Hepatocellular Enzymes – AST (aspartate aminotransferase) and ALT (alanine aminotransferase)
AST and ALT are enzymes contained within liver cells. When levels are increased in the blood, it means that the enzymes have leaked out of the liver cells due to cell damage. AST is found in muscle cells as well as liver cells, so an elevation in AST without a similar elevation in ALT may indicate muscle damage rather than liver damage. Although ALT elevations are specific for liver, there are many non-liver diseases that can indirectly affect the liver and cause increases in ALT. For example, heart failure and intestinal inflammation can cause an increase in ALT up to 4 or 5 times the normal range. Even severe dental disease can cause an elevation in ALT. In terms of primary liver issues, ingestion of certain toxins or chronic inflammation of the liver (due to infection, an over-reaction of the immune system, genetic disorders, etc.) tend to create the most significant ALT elevations.
2) Cholestatic Enzymes – ALP (alkaline phosphatase) and GGT (γ-glutamyl transpeptidase)
ALP and GGT are contained in the cells that line the bile ducts – thin tubes that guide the flow of bile from the liver to the small intestine. If bile flow is blocked, these cells increase production of ALP and GGT and release them into the blood. Causes of poor bile flow within the liver include nodular hyperplasia (a benign condition of older dogs), overwhelming infection, cancerous tumors, and blood vessel abnormalities. However, there are several different forms of ALP in the dog and our routine laboratory tests can’t differentiate between them. Dogs under a year old usually have an elevated ALP as a result of bone growth, as there is a form of ALP associated with bone (B-ALP). Dogs taking steroid medication often have an elevated ALP because there is a form stimulated by the presence of steroids (C-ALP). These elevations are not indicative of liver dysfunction. Certain dog breeds, such as Scottish terriers, Siberian huskies, and miniature Schnauzers, also tend to have benign elevations in ALP. And just as with the hepatocellular enzymes, the cholestatic enzymes will also increase due to the effect of non-liver diseases on the liver. Pancreatitis, gall bladder disease, intestinal inflammation, and certain endocrine diseases all increase ALP.
Other routine lab results can also help us identify liver disease. Since the liver is responsible for making albumin (a blood protein) and cholesterol, a low albumin or low cholesterol level might be the result of severe liver disease. Yellowing of the eyes and skin, also known as jaundice or icterus, can occur when the liver is not effectively removing broken-down old red blood cells from circulation. Low blood sugar can result when a diseased liver is not able to release its stored energy.
As you can see, an elevation in liver values doesn’t necessarily mean there is a serious problem with your dog’s liver. Your veterinarian will take into consideration your dog’s breed, age, medical history, as well as recent medications and additional lab results, to determine if there is a benign explanation for the lab results, if monitoring liver values for several months is appropriate, or if further diagnostics are warranted. Additional diagnostics might include x-rays, an abdominal ultrasound, more blood tests (bile acids, ammonia level), or liver biopsy. In any case, the liver has an amazing capacity to regenerate, so the presence of even significantly elevated liver values doesn’t necessarily mean a poor prognosis.
Tests for Liver Disease
A small amount of blood may be taken and tested for one or more of the following:
AFP (alpha fetoprotein). This is a protein made by the liver. A high level in the blood can be a sign of liver cancer or liver injury and regeneration in adults.
Albumin. This is a liver function test. It measures a protein made by the liver. When a person has liver disease, the level of albumin in the blood (serum albumin) is often low.
Alk phos (alkaline phosphatase). This is an enzyme that is mostly made in the liver and bones. It’s measured with a blood test. A high level suggests a problem with the bile ducts in the liver.
ALT (alanine aminotransferase). ALT is an enzyme made by the liver. When the liver is damaged, ALT leaks into the blood. If a blood test finds a high level of ALT, this can be a sign of liver problems such as inflammation, scarring, or a tumor.
Ammonia. This is a liver function test that shows when a harmful substance is left behind in the blood after digestion. Normally the liver removes ammonia from the blood and turns it into urea. This leaves the body with urine. If a blood test shows that the ammonia level is too high, this process isn’t happening as it should. This test is very inaccurate for liver function and should rarely be used.
AST (aspartate aminotransferase). AST is another enzyme made by the liver as well as by other organs such as muscle. It too is measured with a blood test. High levels of AST may be a sign of liver injury, especially if the ALT level is also high.
Bilirubin. This is a liver function test. It measures the yellow substance made when the body breaks down red blood cells. Bilirubin is collected by the liver to be sent out of the body with stool. When something is wrong with the liver or bile ducts, bilirubin may build up in the body. This causes yellowing of the skin and the whites of the eyes (jaundice). Two measurements may be taken from this test: total bilirubin and direct bilirubin. A high bilirubin level may be the result of liver disease or a blockage in the bile ducts. A high indirect bilirubin can mean a condition called Gilbert syndrome. Only a small portion of people have Gilbert syndrome. Gilbert syndrome is not a sign of disease. A high indirect bilirubin can also be a sign of rapid red blood cell breakdown.
CBC (complete blood count). This is a test that measures all the parts of the blood. These are red blood cells, white blood cells, and platelets. Problems with these counts can mean infection or illness. They can also be a sign of a problem with the spleen. The spleen is an organ close to the liver that can be affected by liver disease. A low platelet count is common with advanced fibrosis of the liver. It also happens when the spleen becomes enlarged and begins to absorb platelets.
GGT (gamma-glutamyl transpeptidase). This is a liver enzyme that’s often measured along with other enzymes to gauge liver problems. GGT is measured with a blood test. If alk phos and GGT are both higher than normal, it may be a sign that the bile ducts in the liver may be diseased or blocked. It also can be a sign of fatty liver or alcohol damage.
Glucose. This is a sugar in the blood and the body’s most important source of energy. A healthy liver helps the body maintain a normal glucose level. If a blood test shows that glucose is low, this may mean the liver is not working properly.
Infectious hepatitis. This is a disease and can be found with antibody and antigen tests for Hepatitis A, B, C, D, and E.
PT (prothrombin time) or INR (international normalized ratio). This checks how long it takes for blood to form clots. The liver makes a protein that helps with clotting. Problems with clotting can be a sign of liver disease.
5NT (5′-nucleotidase). This is enzyme is made is several organs, but only released into the blood by the liver. A high or low level may be a sign of liver disease.
SBA (serum bile acid). This test measures the amount of bile acid in the blood. A high level may mean that bile ducts are blocked or that the liver is unable to excrete bile acid. This test is rarely done.
Vitamins A, D, E, and K. These vitamins are stored in the liver and fat and released over time (fat-soluble). They are absorbed by the liver, with help from bile. If a blood test shows that these vitamin levels are low, this could mean the liver is not absorbing them properly.
Zinc. This is a nutrient that is absorbed by the liver. If a blood test shows a low zinc level, this could mean the liver isn’t absorbing zinc properly. This can worsen conditions brought on by high levels of ammonia.
Several other lab tests may be done to check for specific liver problems once liver damage is found. These include:
Biochemical blood test that shows
To diagnose diseases, patients are assigned tests, according to the results of which their state of health is determined. The most complete, allowing you to accurately and accurately diagnose, is a biochemical blood test. The study is necessary to obtain an extensive and objective understanding of the state of individual organs and the whole organism. Along with the general analysis of urine and blood, biochemistry has been used for laboratory diagnostic purposes for many years.Finds practical application in all medical fields: therapy, gynecology, cardiology, oncology, urology, gastroenterology and others. Biochemistry is of particular value in diseases of the heart, endocrine system, kidneys and liver.
Blood is a separate tissue of the human body. Its unique feature is that it is found in all organs and other tissues. The blood contains substances that are formed during the functioning of the body.Biochemical analysis allows you to determine the presence and level of their content. Comparison of the obtained data and normal indicators makes it possible to draw conclusions about the functioning of organs and pathologies in them. Biochemical analysis is a laboratory study of a large number of enzymes, mineral and organic substances. It characterizes carbohydrate, protein, fat and mineral metabolism in the body. The existence of pathology in a particular organ is shown by changes in metabolism.
The analysis is carried out when there is a suspicion of a hidden current disease.According to its results, pathology is detected at the earliest stage, which allows prescribing timely treatment and stopping the process. The method, which is characterized by a high degree of information content and reliability, is the basis for medical diagnostics, and allows one to judge the state of vital organs. Recommended to be carried out at least once a year. For individual diseases, biochemistry is the only option for an objective diagnosis. In addition to the standard biochemical analysis, a study of specific indicators used in genetics, endocrinology, pediatrics, and sports medicine is carried out.
Blood in the amount of 5-10 milliliters is taken from a vein, then placed in a test tube. Before taking the test, for a more accurate result, you should not eat and take medications, if this is not a health risk.
The interpretation of the results is carried out according to the following indicators:
- The level of sugar and glucose – its increase is a sign of the development of diabetes mellitus, a sharp decrease is life threatening;
- Cholesterol – its increase indicates vascular atherosclerosis and the risk of heart and vascular diseases;
- Transaminases – enzymes that can detect myocardial infarction, hepatitis or the presence of trauma;
- Bilirubin – its high level indicates liver pathology, violations of the outflow of bile and destruction of red blood cells;
- Creatine and urea – an excess of them indicates a weakened function of the excretion of the liver and kidneys;
- Total protein – a change in this indicator indicates negative processes in the body or serious diseases;
- Amylase is an enzyme of the pancreas, an increased value of which is a sign of pancreatitis.
During the analysis, more than 20 elements are examined. In addition to the above, biochemical analysis reveals the content of iron, potassium, chlorine, phosphorus, etc. in the blood.
Indications for prescribing a biochemical blood test
Biochemistry is usually prescribed to patients undergoing outpatient or inpatient treatment. The study is assigned to diagnose or to monitor the ongoing treatment. The definition of certain indicators is assigned individually, depending on the disease.From the general list, indicators are selected that have a priority value for diagnostics.
Most often, biochemistry is prescribed for pathology:
- hepatobiliary system;
- endocrine system;
- blood systems;
- musculoskeletal system;
- gastrointestinal tract.
The analysis is deciphered by the attending physician, who prescribes the treatment.
How to donate blood for biochemistry
The day before blood sampling, it is necessary to give up fatty, spicy and fried foods, strong coffee, tea, dark chocolate, alcoholic beverages, including beer. Certain substances in food may temporarily interfere with results. For example, drinking coffee the day before increases the white blood cell count, and alcoholic drinks increase the level of uric acid. According to distorted data, the doctor can give an unreasonable conclusion about the patient’s state of health.
Blood is donated on an empty stomach, you can drink a glass of water. Stop smoking for two hours before donating blood. Before taking the analysis, you can not drink pills, do massage, warming up and x-rays. During the procedure, in order not to increase the levels of cholesterol, creatinine, alkaline phosphatase, etc., you need to sit or lie down. Physical activity is also contraindicated. Blood is taken from the ulnar vein, if they are poorly visible, from the hand or foot.
norm in the 1st, 2nd and 3rd trimester
Why is research important?
The body of a pregnant woman undergoes severe stress and significant restructuring.This often leads to exacerbation of chronic diseases and the emergence of new pathologies.
A biochemical blood test is an important element of screening during pregnancy. The analysis allows:
- to evaluate the functions of internal organs;
- to determine violations of water-salt metabolism;
- to identify the lack of trace elements;
- to diagnose diseases in the early stages.
What are the indications for a pregnant woman to be tested?
The doctor does not need any reason to order a study. The analysis is mandatory and is carried out several times during pregnancy: in the first trimester when registering, as well as in the second and third trimesters. For certain indications, a study may be prescribed additionally.
Blood sampling is performed from a vein, in the morning and on an empty stomach. Proper preparation for research is as follows:
- the interval between the last dinner and analysis must be at least 12 hours;
- only water can be consumed immediately prior to analysis.Juices, coffee, tea and other drinks are prohibited;
- 48 hours before the study, you need to give up physical activity and try to avoid stress.
Indicators of biochemical blood test
A biochemical blood test is a complex study consisting of many tests.
Total protein and albumin
Total protein shows the serum content of all types of proteins. Proteins are responsible for the transport of nutrients, protect the body from infections, serve as building blocks for cells, tissues and organs, maintain hormonal balance in the female body.
Protein levels may decrease during pregnancy. This occurs due to the consumption of substances for the construction of fetal cells.
Pathological reasons for a decrease in protein can be:
- diseases of the liver, kidneys;
- malfunction of the thyroid gland;
- internal bleeding.
Protein concentration increases in inflammatory processes, systemic pathologies, autoimmune diseases, acute intestinal infections.
Albumins are proteins with a low molecular weight. The concentration of these substances affects the osmotic pressure of the blood, which regulates the water exchange between tissues and blood.
Albumin is optional. It is mainly determined in pregnant women in the following situations:
- with the appearance of edema;
- with gestosis;
- with an increase in total protein levels.
Urea and creatinine
Urea and creatinine are chemical compounds that are formed as a result of the breakdown of proteins and are excreted from the body by the kidneys.The concentration of these substances allows you to assess the work of the urinary system. For example, with kidney dysfunction, the products of protein metabolism accumulate in the blood, causing intoxication of the body. High levels of urea and creatinine can cause pathologies that are dangerous for the pregnant woman and the fetus.
During pregnancy, the risk of kidney disease increases dramatically. This happens for the following reasons:
- Due to hormonal changes, immunity decreases and the body becomes susceptible to viruses and bacteria.As a result, the likelihood of developing pyelonephritis and other inflammatory kidney diseases increases;
- The enlarged uterus compresses the ureters, which leads to stagnation of urine in the kidneys.
High urea and creatinine can be observed in pregnant women with urolithiasis, renal failure, diabetic nephropathy, inflammation of the urinary tract.
In addition, the concentration of urea and creatinine allows you to track the condition of other organs.For example, a low urea content is observed in liver pathologies.
In human blood, cholesterol is contained in the form of complex compounds with special proteins. Depending on the density of complex compounds, cholesterol can be divided into several types:
- HDL – “good cholesterol”, which provides cell membranes with strength and elasticity, promotes the production of vitamin D in the body, takes part in the synthesis of sex and steroid hormones;
- LDL – “bad cholesterol”.An excess of the substance reduces the functionality of HDL and leads to the formation of atherosclerotic plaques on the walls of blood vessels. A high level of LDL is observed in hypothyroidism, diabetes mellitus, systemic connective tissue diseases, and obesity.
During the period of gestation, cholesterol levels rise. This is due to changes in hormonal levels and metabolism in the female body. Therefore, special norms have been developed for pregnant women, which should be taken into account when decoding the analysis.
In a healthy pregnant woman, blood glucose (glycemia) is within certain physiological limits. Higher values may indicate type I or type II diabetes, or gestational diabetes (GDM).
GDM is the most common metabolic disorder in pregnant women encountered by endocrinologists and obstetricians-gynecologists. The main cause of the disease is a change in hormonal levels.Most often, with GDM, there is no pronounced symptomatology, which makes diagnosis difficult. Determination of glucose in biochemical analysis is one of the ways to identify pathology. GDM requires immediate treatment, as it can cause miscarriage, affect the health of the unborn child and the woman herself.
ALT and AST
ALT and AST are enzymes of the transaminase subgroup that are considered major markers of liver disease. In case of damage to the parenchyma of an organ, substances in large quantities enter the bloodstream, which indicates the presence of pathology.
In addition, the level of enzymes allows you to track the work of the cardiovascular system, the state of skeletal muscles.
The synthesis of substances is associated with the content of vitamin B6 in the body. Accordingly, with a lack of this vitamin, the ALT and AST values will be lowered.
Bilirubin is a substance that is formed when erythrocytes are destroyed. Mostly this process takes place in the liver, therefore, first of all, the value of bilirubin reflects the work of this organ.
The results of biochemical analysis indicate the values of three types of bilirubin:
90,018 90,019 total;
Indirect bilirubin is very dangerous: its high content in the blood causes intoxication of the body. Direct bilirubin is water soluble and less toxic.
If the pregnancy proceeds without complications, then the indicators of the three types of bilirubin do not deviate from the reference values. Acute and chronic hepatitis, liver tumors can cause increased results. Also, high numbers are observed with severe toxicosis.
Alpha-amylase is an enzyme that breaks down starch into simpler saccharides and is involved in the digestion process. Without this substance, the body would not be able to assimilate carbohydrates as the main source of energy.
An increase in the enzyme during pregnancy can indicate the following problems:
- diabetes mellitus;
- pancreatitis – inflammation of the pancreas;
- cholecystitis – inflammation of the walls of the gallbladder;
- renal failure – impairment of all renal function;
- Ectopic pregnancy – the attachment of a fertilized egg outside the uterine cavity.
Alkaline phosphatase (ALP)
It is the most abundant enzyme in the body and is present in all tissues and organs. The substance takes part in the transport of phosphorus and accelerates the decomposition of complex compounds of phosphoric acid. Determination of the amount of the enzyme is necessary to assess the state of the liver, kidneys, gallbladder, bone tissue and other organs and structures.
In the second trimester of pregnancy, fetal placental alkaline phosphatase begins to enter the maternal bloodstream.A woman’s ALP level rises and reaches its maximum in the third trimester.
The physiological increase in the concentration of the substance is not dangerous and is not considered a pathology. But if the result of the analysis significantly exceeds the reference values, then this may indicate the presence of diseases:
- gestational diabetes mellitus;
- gestational dermatosis;
- inflammatory processes of the liver, kidneys, gallbladder.
Microelements are substances that ensure the full functioning of the body.A lack of trace elements in a pregnant woman can adversely affect the endocrine, nervous, digestive system, and also lead to fetal abnormalities. Therefore, it is so important during pregnancy to check the content of these nutrients in the body.
Biochemical analysis determines the level of calcium, iron, sodium and other trace elements. When prescribing an analysis, the doctor determines the number of positions studied, taking into account the individual characteristics of the patient. With a deficiency of any substance, a correction of the diet or the intake of vitamin-mineral complexes is required.
Online consultation of a gynecologist
As part of the consultation, you will be able to voice your problem, the doctor will clarify the situation, decipher the analyzes, answer your questions and give the necessary recommendations.
Table: reference values of a biochemical blood test during pregnancy by trimester
Total protein level
g / l
g / l
mmol / l
mmol / l
mmol / l
unit / l
up to 32
up to 31
up to 31
unit / l
up to 31
up to 30
up to 30
μmol / l
μmol / l
μmol / l
Up to 7.9
μmol / l
unit / l
unit / l
μmol / l
mmol / l
mmol / l
mmol / l
mmol / l
mmol / l
A biochemical blood test during pregnancy is an important analysis that is mandatory.The results of the study make it possible to assess the state of the female body, to predict the course of pregnancy and childbirth.
LIVER DISEASES. DIAGNOSTICS. PREVENTION RECOMMENDATIONS.
The liver is a vital human organ that performs a number of critical functions for the body, such as:
- Production of bile , which helps the body to get rid of metabolic waste products and also dissolves fats in the small intestine during digestion.
- Synthetic function . The liver plays an important role in the production of proteins that are released into the blood and have a number of important functions (hemostasis, fibrinolysis, hormonal action and immunity, transport of substances, etc.)
- Detoxification of blood from harmful substances (toxins, alcohol, medicines)
- Accumulation of various useful substances , such as vitamins and minerals (A, D, B12, vit.K, iron, copper), glucose in the form of glycogen.
That is why liver disease is a very important medical problem all over the world. Liver disease can be congenital or acquired due to various factors that damage the liver, such as viruses and excessive alcohol consumption. Obesity is also an important factor in liver damage. Over time, permanent liver damage results in scarring (cirrhosis), which can lead to liver failure, a life-threatening condition.
Signs and symptoms suggestive of liver disease:
- Skin and eyes appear yellow (jaundice)
- Abdominal pain
- Leg edema
- Itchy skin
- Dark urine
- Discolored or bloody stools
- Chronic fatigue
- Nausea and vomiting
- Loss of appetite
- Bleeding gums, frequent bruising.
The causes of liver damage are varied, the main and most frequent ones are:
- Infection. Parasites and viruses can infect the liver, causing inflammation and dysfunction. The most common types of liver infections are viral hepatitis A, B, C.
- Alcohol. Excessive and / or chronic alcohol consumption is a common cause of liver disease. The risk of cirrhosis increases significantly with concomitant viral hepatitis.There is currently no clear amount of ethanol associated with liver damage.
- Non-alcoholic liver disease (Non-alcoholic fatty liver disease) is a collective term for a number of liver disorders that affect people who do not drink or consume little alcohol. As the name suggests, an excess amount of fat accumulates in the liver cells.
Main causes of non-alcoholic liver damage:
- Overweight and obesity
- Insulin resistance (a condition in which cells do not take sugar from the blood in response to insulin stimulation)
- Prediabetes and Diabetes
- High blood fats, especially triglycerides.
- Also, risk factors (conditions in which the likelihood of non-alcoholic liver disease is significantly increased) include:
- Metabolic syndrome (hypertension, high blood glucose and cholesterol levels, increased waist circumference due to adipose tissue)
- Sleep apnea ( respiratory arrest)
- Polycystic ovary syndrome
- Decreased thyroid function (hypothyroidism)
- Pathology of the immune system.Diseases in which the immune system attacks its own cells (autoimmune diseases) can damage the liver. The main diseases are as follows:
- Autoimmune hepatitis
- Primary biliary cirrhosis
- Primary sclerosing cholangitis
- Genetic (congenital) causes. A defective gene inherited from one or both parents can cause the accumulation of various substances in the liver, which leads to its damage.Genetic liver diseases are as follows:
- Wilson’s disease
- Cancer and other creations, for example:
- Liver cancer
- Bile duct cancer
- Liver adenoma
Risk factors that increase the likelihood of liver disease:
- Excessive alcohol consumption
- Injecting drug use
- Tattoo or Piercing
- Blood transfusion
- Contact with blood and other people’s fluids
- Unprotected sex
- Contact with certain chemicals or toxins
- High blood cholesterol and triglyceride levels
Diagnostics of liver diseases
When to see a doctor.
If you develop and continue any of the symptoms listed above, be sure to consult a doctor to find out their cause and eliminate them. In case of severe abdominal pain, seek immediate medical attention.
Recommendations doctors of the CLINIC “GEMO MEDICA” How to prevent liver diseases:
- Drink limited amount of alcohol
- Be careful (use condoms, make sure tattoo and piercing parlor equipment is sterile, do not use disposable needles twice)
- Get vaccinated (there are vaccines against hepatitis A and B)
- Avoid contact with other people’s blood
- Take medication strictly as recommended by your doctor
- Be careful with aerosols, paints and other toxic substances, use personal protective equipment
- Maintain a normal body weight.
If you have any questions regarding the condition of your liver, you can always contact the clinic “GEMO MEDICA”.
Here you can undergo all examinations: ultrasound of the liver, CT of the liver, laboratory diagnostics, in particular, to examine the functions of the liver, to identify parasitic or viral lesions. Today, we can do the so-called ultrasensitive PCR diagnostics , which allows us to detect the smallest amount of hepatitis B and C viruses (from 5 MO in 1 ml of blood, while standard PCR diagnostics can only detect more than 100 IU of the virus in 1 ml).Also in our clinic you can get qualified consultations of experienced doctors .
So, you can have a complete examination of your liver in one institution.
We really care about you.
Author: Zheka Andrey Yurievich, family doctor, medical consultant.
Biochemical blood test – to pass the analysis at SZCDM
Biochemical blood test (BAC) is one of the most informative tests that gives an idea of the functioning of the kidneys, liver, gallbladder, pancreas, other organs, lipid, protein and carbohydrate metabolism, and the balance of trace elements.
A LHC can be prescribed by any doctor, because with each disease it is important to see the big picture. For preventive purposes, blood biochemistry is done once a year, during pregnancy – in the 1st and 3rd trimesters with a normal course and more often – with a woman’s ailments and complaints about her well-being.
Indications for analysis:
complaints of malaise;
assessment of the state after therapy;
Studies during the biochemical blood test
During biochemical analysis, blood sugar, urea, total lipids, low and high density cholesterol, triglycerides, total bilirubin, total protein, AsAt, AlAt enzymes, lipase, amylase, gamma-GTP and other indicators are determined.
Each of the indicators may indicate the normal functioning of an organ, system, or a deviation from the norm.
It should be remembered that blood biochemistry is a primary diagnosis, an assessment of the general health of a person. Its results can only be interpreted by an experienced specialist. According to the indicators of the LHC, the doctor prescribes special tests if there are suspicions of a disease or organ pathology.
A biochemical blood test is a large number of test items. Next, we will talk about the main ones.
Further in the text there are research norms WHICH HAVE AN INTRODUCTORY CHARACTER.
In all laboratories, the norms, units of measurement may differ, as well as THEY DEPEND on the gender and age of the patient.
Specific proteins and markers of inflammation
More than 20 plasma proteins are called specific proteins and markers of inflammation, the concentration of which indicates the development of acute inflammation or tissue damage.
CRP is one of the most sensitive markers of acute inflammation and tissue damage. It appears in the serum and rapidly increases in volume when:
diseases of the gastrointestinal tract;
parasitic, viral, bacterial infections;
systemic rheumatic diseases;
metastases of cancerous tumors;
tissue damage, including acute myocardial infarction;
sepsis of newborns;
taking oral contraceptives, estrogens.
From the above list, it is clear that the indicator has low specificity, therefore, with its high indicators, more narrow studies are immediately prescribed if the reason for the increase is unknown.
The CRP indicator is used to determine the success of therapy: if the treatment is successful, the protein is normalized after 6-10 days
Eosinophilic cationic protein (ECP)
ECP rises when:
atopic bronchial asthma;
acute respiratory infections;
malignant diseases with eosinophil activation;
taking certain medications.
Rheumatoid factor – proteins that are produced by the human immune system. An increase in the RF rate may indicate rheumatoid arthritis, Sjogren’s syndrome, chronic infections of a bacterial, viral, parasitic nature, some types of oncology, diseases of the kidneys, liver, and lungs.
The concentration of myoglobin increases if the myocardium or skeletal muscle is damaged.Normally, its concentration is not determined in the laboratory – so little myoglobin is found in the blood of a healthy person, from 0 to 70 μg / l.
Tn I is a protein of the heart muscle that enters the bloodstream during myocardial infarction. It belongs to the most sensitive and specific indicator for damage to the heart muscle. After a heart attack, approximately 3 hours later, the level of Tn I in the blood rises significantly and remains so for up to 14 days.
Creatine kinase MB
KK-MB is a cell enzyme that is used as a specific and sensitive indicator of myocardial damage.
KK-MB is located almost in full in the heart muscle, therefore, its content in the bloodstream is negligible. If it increases, then there is a high probability of an acute heart attack, recurrent heart attack and other pathological processes associated with the heart.
NT-proBNP is a protein of the left ventricle of the heart. A change in its level may indicate heart failure, its severity. The level of this protein is also used to assess the effectiveness of therapy for heart failure.
The norm for people under 75 years old is 0-125 pg / ml, over 75 years old – up to 450 pg / ml.
ASLO is a marker of streptococcal infection. Its increase is caused by tonsillitis, scarlet fever, chronic tonsillitis, acute glomerulonephritis, streptococcal pyoderma.
Procalcitonin increases in the blood during bacterial infections, sepsis, septic shock, multiple organ failure and some other serious conditions.
Electrolytes include chlorine, sodium, potassium. They play an important role in metabolic processes, maintain acidity and water balance. Electrolyte levels are the most important characteristic of human health, an indicator of the functionality of the heart and kidneys.
Abnormalities in kidney function, heart disease, diabetes mellitus, pathologies and disorders in the work of muscles and the nervous system lead to a deviation from the norm.If the electrolyte imbalance is not stabilized, eliminating its causes, the person will experience dizziness, convulsions, and irregular heart rhythms. In especially advanced cases, electrolyte imbalance leads to death.
The LHC shows the level of fat and allows you to assess the risk of occurrence, development of heart, vascular diseases. During testing, the level of triglycerides, cholesterol – total, LDL, HDL is checked.
Triglycerides grow in diabetes mellitus, cardiac and vascular pathologies, pregnancy; decrease in case of disorders in the thyroid gland, at the terminal stage of liver damage, if a person eats poorly, monotonously.
HDL (“good cholesterol”). Participates in the processing and removal of fats from the body. If the values are high, the risk of vascular plaque formation decreases.The norm is 1.03-1.55 mmol / l.
LDL (“bad cholesterol”). Normally – 0-3.3 mmol / l – it is necessary for the body. Exceeding the norm threatens the development of atherosclerosis.
General (composed of HDL and LDL). The normal indicator is 5.2 mmol / l. Decrease against the norm leads to psychophysiological disorders, reproductive dysfunction. Elevated levels can cause diabetes mellitus, atherosclerosis.
During the LHC, glucose and fructosamine levels are examined. An increase in their level can occur with diabetes mellitus, a decrease – with pancreatic tumors, when taking insulin.
the norm for glucose is 3.3–5.5 mmol / l;
the norm for fructosamine is up to 285 μmol / l.
During the LHC, the level of bilirubin is set – total (yellow), direct, indirect.
General. Normally – 3.4-17.1 μmol / l, an increase occurs in pathologies, liver diseases, disruption of its work.
Straight. Normally – up to 7.9 μmol / l, an increase signals liver and biliary tract pathologies.
Indirect. Its indicators are calculated, depend on direct and total bilirubin. An increase in indirect bilirubin is often associated with anemia, malaria.
Serum iron is one of the most important health indicators. It transports and stores oxygen, participates in hematopoiesis, is part of many proteins and enzymes. Especially carefully you need to monitor the level of iron in children, adolescents, pregnant and lactating women, the elderly, those who are experiencing high physical activity, suffering from chronic bleeding.
A decrease in the level of iron occurs with improper diet, profuse blood loss, non-assimilation of iron, increased need for it.
The standard set of LHC indicators includes the so-called. “Liver tests” – ASAT, ALAT.
The norm of ASAT is up to 31 U / l in women, up to 37 U / l in men.
The ALAT norm is up to 34 U / L in women, up to 45 U / L in men.
Changes in the norm can signal diseases, pathologies of the liver, heart, inflammation and infections.
Amylase is an enzyme in the digestive juice. An increase in its level occurs in acute, chronic pancreatitis, other diseases (including tumors) affecting the pancreas.
The rate of amylase is 28-100 U / l.
Pancreatic amylase – P-type amylase. An increase in the level of P-type amylase occurs when the pancreatic duct is blocked by a tumor, stone, and in some other cases.
CC is an enzyme that provides energy for muscle contraction. In the blood, it is present in different isomers. By increasing the concentration of individual isomers, an assumption is made about muscle damage, myocardium, and oncological diseases.
Lipase is an enzyme in the digestive juice. A change in the norm indicates problems with the pancreas.
The standard BAC determines the concentration of vitamin B12. It is necessary, first of all, for hematopoiesis. An increase in the level of B12 occurs in diseases of the kidneys, liver, leukemia, a decrease – in vegetarianism, inflammation of the gastrointestinal tract, parasitic infections. The norm of the vitamin is from 208 to 963.5 pg / ml.
The LHC may include a test for the content of vitamins of group D. Up to 60% of people around the world are deficient in this vitamin.Vitamin deficiency is expressed in rickets (children), muscle weakness, pain in the pelvic bones, lower back, legs. With vitamin intoxication (uncontrolled intake of vitamin-containing complexes), headaches, nausea, vomiting, metallic taste in the mouth, acute pancreatitis, nephro- and arteriocalcinosis occur.
The norm for vitamin D2 is 0.8-7 ng / ml, for vitamin D3 it is 2.2-42.6 ng / ml.
Rules for preparing for analysis and delivery of the LHC
Many factors affect blood counts: food (including drinking water), habits, physical and mental condition, bathing, medications, alcohol, smoking, etc.Therefore, in order to obtain accurate data, several requirements must be met:
donate blood on an empty stomach, from 8 to 11 am (all laboratory parameters are calculated for this time, they change over the course of the day). Even water is recommended not to drink whenever possible. At least 8 hours should pass since the last meal, ideally 12 hours;
on the eve, or better for a few days, you should give up heavy, fatty, fried foods, strong tea, alcohol, carbonated drinks, and other foods that can change the functioning of the liver, kidneys, pancreas;
a day before the analysis, avoid physical, psychological overload, do not go to the bathhouse, solarium, do not do x-rays, fluorography, physiotherapy, ultrasound;
refrain from taking medications a day before the analysis.If this is not possible, you need to inform the doctor and follow his recommendations;
do not smoke 2 hours before donating blood;
just before donating blood, sit for 15-20 minutes to calm down, stabilize breathing, pressure.
Important! The rules for donating blood for the LHC may differ in different laboratories, therefore, it is necessary to clarify them before testing.
How the study is conducted
For research, take blood from a vein.
Cost of biochemical blood test at SZDTSM JSC
In order to clarify the cost of the studies you are interested in, you need to call the call-center or familiarize yourself with the price list presented in the “Analyzes and Prices” section.
Where to take a biochemical blood test
Analyzes can be taken in any division of SZTsDM JSC, which is most conveniently located to you geographically.
And it is also possible to order a nurse’s visit to your home or office, the departure is FREE OF CHARGE, only the collection and analyzes are paid in accordance with the presented price list and with the preservation of all cumulative discounts, if any.
90,000 Liver Cancer – Docrates
Among men, cases of liver cancer are twice as common as among women, due to the difference in alcohol consumption.One of the most common types of liver cancer is liver cell cancer (primary cancer), in the language of medicine called hepatocellular carcinoma (abbreviation HCC). In turn, a tumor originating from the biliary tract, cancer of the biliary tract (cholangiocarcinoma), is less common. What these cancers have in common is that they most often occur in the liver as a consequence of cirrhosis or chronic biliary tract disease. In medicine, biliary tract cancer can also be classified as a type of gallbladder cancer.
Hepatocellular carcinoma can metastasize to other parts of the liver, although not as often as other types of cancer, and is diagnosed at a later stage, when metastases have penetrated, for example, into bone tissue or lungs. Often, in the early stages, the tumor grows and progresses very slowly. Advanced liver cancer can cause internal bleeding, ascites, or liver failure.
Liver cancer risk factors
Cirrhosis and other liver diseases are the leading cause of liver cancer in Western countries.According to the majority of experts in the world, it is most often caused by chronic inflammation of the liver caused by the hepatitis B virus. In Africa and Asia, hepatitis B and C are very common and, as a result, cirrhosis and liver cancer are quite common there. In Finland and other Western countries, alcohol abuse is the most common cause of cirrhosis. However, rare liver diseases that have nothing to do with alcohol consumption can also cause liver cancer.In Western countries, a growing health threat is being overweight, which leads to excessive accumulation of fat in the liver and metabolic syndrome, which increase the risk of cancer. This problem is especially acute in the United States, but is gaining momentum in other countries.
In addition, a disease such as hemochromatosis also causes cirrhosis and liver cancer. Hemochromatosis is a violation of iron metabolism, due to which excess iron accumulates in the liver, pancreas and other organs.If this disease is left untreated, the risk of primary liver cancer increases by about 200 times. However, if the problem is eliminated in time, before cirrhosis of the liver has developed, then the risk of getting cancer is reduced to nothing.
Other risk factors include diabetes, old age and smoking.
Symptoms of liver cancer
In most cases, primary liver cancer is asymptomatic, which is why the correct diagnosis is delayed. Most often, signs of the disease appear already when the tumor has spread outside the liver or metastasized to other organs.Symptoms of primary cancer are common symptoms that can be associated with various ailments, and people do not always think about the fact that it can be cancer.
Fatigue, a feeling of heaviness in the upper abdomen, and loss of appetite may signal the presence of a malignant neoplasm. If the swelling is painful and is felt in the upper abdomen, it may already have grown to a fairly large size. Secondary symptoms of liver cancer include weight loss, sometimes fever, vomiting, and yellow skin.The latter occurs because the liver is no longer able to remove bilirubin from the blood. Itching can also be a sign of liver cancer due to changes in bile acid levels in the blood.
Diagnosis of liver cancer
If liver cancer is suspected, blood tests and liver counts are usually taken first. Almost always, a blood test can be used to determine whether a person has liver cancer or not.
With the help of computed tomography (CT) and magnetic resonance imaging (MRI), accurate images are obtained, which greatly simplifies the diagnosis.Computed tomography allows you to see if the tumor has spread to nearby tissues or blood vessels. During a diagnostic study, a sample of tumor tissue is taken (biopsy). This is necessary in order to determine whether the patient has cancer or not. A biopsy is the only way to determine if a liver mass is benign or malignant. If the presence of a malignant tumor is confirmed, then the degree of its prevalence is determined.
If liver cancer is suspected, laboratory tests are also carried out.A blood test is taken for alpha-fetoprotein AFP (liver tumor marker), the level of which is increased in 80% of patients with primary liver cancer. If the AFP level increases over time, then this is a clear indicator of the presence of cancer. When choosing methods for treating liver cancer, blood tests are also taken to examine the disorders of its work, which are often a consequence of a disease that precedes the cancer.
Liver cancer treatment
Treatment of liver cancer is planned on a case-by-case basis, depending on the extent of the tumor, how the liver works, and the general condition of the patient.The choice of the type of treatment is also influenced by possible concomitant diseases and medications taken. The main criterion for whether surgery can be performed is the localization of the tumor in relation to the main vascular systems and structures of the biliary tract, as well as the size and number of malignant neoplasms.
Treatment may consist of one or more of the following methods:
Surgical intervention is the only treatment with a chance of recovery.However, in this case, the tumor must be resectable, i.e. small in size and is located in the section of the liver, from where it can be removed. In addition, the organ must be relatively healthy. Often, at the time of cancer diagnosis, the liver is already in a rather poor condition due to cirrhosis, and therefore, surgical intervention is possible in extremely rare cases.
Approximately one quarter of all organ tissue can be safely removed during surgery. However, this is possible if liver failure is not too severe.Provided the liver is generally healthy, up to 70-80% of the tissue can be removed. If the liver is damaged, but the size of the tumors is small and the number is from 1 to 3, liver transplantation can give good results.
If the operation is not possible, then other methods of treatment can reduce the tumor or slow its growth. In the presence of one or only a few tumors, in some cases it is possible to resort to a method of local exposure, for example, radiofrequency thermoablation. During this procedure, a needle electrode is inserted directly into the tumor, which transmits radio frequency radiation and heats the tumor for a short time to a high temperature, thereby destroying cancer and healthy cells.
During chemoembolization (TACE method), the drug is injected directly into the artery that supplies the tumor with blood. At the same time, the veins feeding the tumor are examined with an embolizing agent. Sometimes, in quite rare cases, the TACE technique is so effective that the tumor is reduced to a size that allows surgery to remove it. In some cases, they resort to selective interstitial radiation therapy (SIRT), the essence of which is that microscopic particles are injected into the artery, which create high-level local internal radiation in the blood vessels of the tumor.
External radiation therapy is used mainly when the spread of the tumor causes pain in the patient. The use of radiation therapy is limited by the fact that healthy liver tissue is very sensitive to this type of exposure.
The only known drug therapy that prolongs the patient’s life is treatment with the targeted antineoplastic agent Sorafenib. It is prescribed in cases where the cancer is already very widespread and does not respond to local treatment (surgery, radiofrequency thermoablation or embolization).Today, new drug methods are being investigated.
Successful treatment of primary liver cancer requires well-coordinated work of oncological surgeons and specialists in chemotherapy and radiation therapy. In Finland, the surgical treatment of liver diseases is at the highest level. In order to choose the right treatment, the Docrates clinic specialists pay special attention to the accurate diagnosis of primary liver cancer at an early stage. Treatment of advanced cancer is carried out here by specialists of the highest level with many years of experience in this area.
Biochemical blood test / “9 months”
No. 3, March 2008 .
During 9 months of pregnancy, the expectant mother has to take a considerable number of tests. Why is this needed and what do their results mean?
Biochemical blood test allows you to evaluate the work of many internal organs – kidneys, liver, pancreas, etc. In addition, a biochemical blood test shows which trace elements are lacking in a woman’s body.Since during pregnancy there are various changes associated with metabolic processes, the assessment of blood biochemical parameters is important for the timely diagnosis of pathological conditions that may arise in the body of the expectant mother.
Let’s list the main indicators of the biochemical blood test.
Total protein – an indicator of protein metabolism, reflecting the total content of all proteins in the blood serum. The normal concentration of total protein in the blood is 63-83 g / l.Plasma proteins are divided into groups with different structures and functions, which are called protein fractions. Among the protein fractions, albumin and alpha, beta, gamma globulins are distinguished. Their definition and ratio allows you to more accurately assess the dysfunctions of internal organs. Physiological hypoproteinemia (decrease in protein levels) can be observed in pregnant women (especially in the third trimester) and during lactation due to a decrease in the number of red blood cells in plasma associated with an increase in total plasma volume.A slight decrease in total protein (55-65 g / l) during pregnancy is not a pathology. An increase in the concentration of protein in the blood serum is observed due to pathology – dehydration and thickening of the blood with fluid loss.
Lipids (fats) – there are 4 main groups of lipids in the blood: cholesterol (cholesterol), tri-glycerides, phospholipids, fatty acids. Cholesterol is the most important indicator of lipid metabolism, serves as a structural component of cell membranes, participates in the synthesis of sex hormones, bile acids, vitamin D.Allocate fractions of low-density lipoprotein cholesterol (LDL), high-density lipoprotein cholesterol (HDL) and some others that differ in composition and function. The content of cholesterol in the blood is highly dependent on age. The normal level of cholesterol in the blood of a young woman is 3.15-5.8 mmol / L. During pregnancy, there is a physiological increase in the level of total cholesterol (up to 6.0-6.2), which is due to the increased formation of endogenous (produced in the liver) cholesterol, which is necessary for building the vascular bed of the placenta and the fetus.An increase in blood cholesterol levels is considered a factor predisposing to the development of atherosclerosis – the formation of specific plaques in blood vessels.
Carbohydrates are the main source of energy for the body.
Glucose is a source of energy and a vital component of any cell in the body. The normal concentration of glucose in the blood in adults is 3.9-5.8 mmol / L. In healthy pregnant women, the glucose level may be slightly lowered (up to 3.5-4.0 mmol / L), as the growing fetus consumes more and more glucose.
During pregnancy, the increased need of the body for insulin (a hormone of the pancreas that regulates carbohydrate metabolism) exceeds the functional capacity of the cells of the pancreas that produce insulin. This can lead to insufficient secretion of it to maintain normal blood glucose levels. During this period, in some pregnant women, the relative lack of insulin can cause the development of gestational diabetes (diabetes during pregnancy), as evidenced by an increase in blood glucose.Therefore, all expectant mothers in the period between the 24th and 28th weeks are recommended to conduct a blood glucose test . This analysis is carried out additionally, without examining other indicators of biochemical analysis.
In the body, specific proteins , which are called enzymes , are involved in all biochemical reactions as catalysts. Each reaction involves its own specific enzyme, so there are hundreds of them. In this case, only a few dozen enzymes are of diagnostic value.
Alanine aminotransferase (ALT) – normally, women have up to 32 U / L. The highest ALT activity is found in the liver and kidneys. ALT levels rise when liver cells, kidney cells are damaged by viruses or chemicals.
Aspartate aminotransferase (ACT) – normally, women have up to 30 U / L. ACT is found in the tissues of the heart, liver, nervous tissue and kidneys; accordingly, it is determined in order to identify the pathology of these organs.During the normal course of pregnancy, ALT and ACT values do not change. A slight increase in transaminases is observed with mild and moderate gestosis. A multiple increase in the activity of ALT (up to 100 IU / L) and ACT (up to 160 IU / L) is observed with severe preeclampsia. This result indicates that the liver cannot cope with the load.
Alkaline phosphatase is present in almost all tissues of the body. The highest activity of ALP is found in the cells of bone tissue, liver, kidneys, intestinal mucosa and placenta.An increase in blood alkaline phosphatase activity is mainly associated with bone diseases and liver pathology. In pregnant women, especially in the third trimester, there is also a physiological increase in the activity of this enzyme, an additional source of alkaline phosphatase in this case is the placenta. Normal values of ALP in adults are up to 150 U / L. In pregnant women, this figure can rise to 240 U / L.
Pancreatic amylase is synthesized by cells of the pancreas.Normally, in adults, it contains up to 50 U / l. The level of pancreatic amylase in the blood increases with pancreatic pathology.
Pigments are colored organic substances. Bile pigments (bilirubin and urobilinogen) and porphyrins (red pigments) are of diagnostic value.
Bilirubin is a bile pigment that is formed as a result of the breakdown of hemoglobin, a pigment in red blood cells, to which oxygen is attached.During the breakdown of hemoglobin, free bilirubin is initially formed, which is transported from the spleen to the liver in combination with albumin. Then, in the liver, free bilirubin binds with a special acid (glucuronic), resulting in the formation of direct, less toxic bilirubin, which is actively secreted into the bile ducts and excreted in the bile. It is one of the main components of bile. Bilirubin is contained in blood serum in the form of two fractions : direct (bound) and indirect (free) bilirubin , together making up total blood bilirubin .The normal level of total bilirubin, including during pregnancy, is 3.4-17.2 μmol / l. With an increase in the concentration of bilirubin in the blood (with accelerated decay of erythrocytes, liver or biliary tract pathology) , jaundice appears. This is due to the fact that with hyperbilirubinemia, bilirubin accumulates in the eyeball and skin.
Nitrous substances are the end products of the breakdown of proteins and nucleic acids – urea, creatinine, creatine, ammonia, uric acid.But in blood biochemistry, urea and creatinine are mainly determined.
Urea – determination of serum urea, along with creatinine, is used to assess renal excretory function. The normal concentration of urea in the blood is 2.5-6.3 mmol / l. An increase in the concentration of urea in the blood is observed in various kidney diseases.
Creatinine – normal creatinine values in women are 53-97 μmol / l. An increase in serum creatinine indicates a decrease in the level of renal filtration (decreased kidney function).The concentration of blood creatinine in pregnant women is physiologically reduced (by 40%) due to an increase in blood volume, an increase in renal plasma flow and filtration, especially in the second and third trimesters of pregnancy. For pregnant women, the normal creatinine level is 35-70 μmol / L.
Trace elements are chemical substances, the content of which in the body ranges from a few micrograms to a few nanograms. But, despite such a small amount, they play an essential role in all biochemical processes of the body.
Iron is a vital trace element involved in oxygen transport. The normal iron level in women is 8.95-30.4 μmol / L. Iron is a part of erythrocyte hemoglobin, muscle myoglobin and some enzymes. With iron deficiency, iron deficiency anemia develops – the most common pathology of pregnancy, which is observed mainly in the second or third trimester due to insufficient satisfaction of the increased needs of the mother and fetus in substances necessary for hematopoiesis.However, with a normal hemoglobin level, a low iron content is possible, which is an indicator of latent iron deficiency anemia – which is why it is important to monitor iron levels in a biochemical blood test during pregnancy. The greatest loss of iron occurs with bleeding.
Sodium – the most important component of the extracellular space, which is associated with the regulation of water distribution in the body. Normal sodium concentration is 136-145 mmol / l. Sodium is involved in the excitation mechanisms of nerve and muscle cells.A decrease in its plasma level causes general weakness and can lead to the development of various neurological disorders. An increase in the concentration of sodium in the blood is observed with restriction of water intake, vomiting, for example, with toxicosis in the first half of pregnancy or diarrhea (loose stools) without replacement of fluid loss.
Potassium is the main intracellular trace element. The normal potassium level in adults is 3.5-5.5 mmol / L. Hyperkalemia is observed with renal failure, drug overdose.With a decrease in the level of potassium, which can be with diarrhea, vomiting, cardiac arrhythmias, muscle weakness, and decreased muscle tone develop.
Calcium is the main component of bone tissue. The normal concentration of calcium in young women is 2.20-2.55 mmol / l. Calcium in the body performs many functions: it participates in the processes of muscle contraction, hormone secretion, regulation of the activity of many enzymes, and the process of blood coagulation. Calcium deficiency is observed during pregnancy, which is explained by the child’s need for building material for bones.When calcium decreases in the analysis, it is necessary to replenish its content with the help of drugs.
Phosphorus – its main part is in bone tissue in the form of calcium salts, the rest is mainly in soft tissues. The normal concentration of phosphorus for the expectant mother is 1.0-1.40 mmol / l. An increase in its content in the blood is observed with an overdose of vitamin D. Decreased function of the parathyroid glands, renal failure.
The biochemical composition of blood is examined twice during pregnancy: at the very beginning of pregnancy, when the pregnant woman is registered and at 30 weeks of pregnancy, if not required more often.Blood for biochemical analysis is taken from a vein in the morning on an empty stomach. At least 12 hours should have passed since the last meal.
We have given a list of necessary, most frequently conducted studies, but in each case the set of the studied items is determined by the doctor. Based on the need, in each specific case, the number of indicators can be reduced or increased.
Nona Hovsepyan, physician of the Independent Laboratory INVITRO
90,000 Albumin – an important serum protein
Albumin (ALB) is a blood plasma protein that has many important functions.It participates in metabolic processes, carries a number of chemicals throughout the body, and so on. Determining the level of this protein plays an important role in assessing liver health. ALB accounts for approximately 60% of total protein.
Biochemical analysis: albumin
Maintaining optimal levels of this protein is extremely important for the functioning of the whole body. The volume of blood circulating in the body depends on this. In addition, protein is responsible for regulating osmotic pressure.This indicator changes under the influence of many factors (for example, after eating salty foods). Therefore, its regulation is a very important process. Albumin is also responsible for the transport and storage of many biological compounds and amino acids. When examining health status, the ALB level is one of the key indicators.
Who needs to be tested
The blood test for albumin is used in combination with data from other studies in the diagnosis of many diseases.Most often, an analysis is prescribed if there is a suspicion of kidney and liver pathology. Also, its results are used to assess the health status of patients with cancer diagnoses, extensive injuries or burns. The test is assigned independently or in combination with other tests. The composition of the examination required in a particular case is determined by the doctor based on the patient’s complaints, the results of the examination, and anamnesis.
Interpretation of results
Albumin is synthesized in the liver.Normally, about 15 grams of protein is produced per day. It is stored in the body and performs its functions for several weeks. The main purpose of this test is to assess the protein-synthetic function of the liver.
An increase in indicators indicates dehydration of the body. The causes of dehydration can vary (eg, severe burns). Also, a high ALB level can indicate the presence of infection and a number of other diseases. For their accurate diagnosis, an additional examination is mandatory.
Lack of protein in most cases indicates kidney pathology. It can also be observed in the presence of an inflammatory process. A decrease in performance during pregnancy is normal. The reference values depend on the age of the patient. For adults, the norm ranges from 35-52 g / l. The test results indicate the severity of a number of diseases.
The amount of ALB is required for the diagnosis of a number of diseases, the choice of the optimal treatment tactics.It characterizes the metabolism, the state of health in general. With severe symptoms of kidney problems, this test is prescribed first. It can also be carried out as part of a comprehensive survey or after it, if deviations are identified and it is necessary to clarify their nature and cause. Interpretation of the results can only be performed by a physician, the test is not intended for self-diagnosis . In some cases, deviations from the norm are possible in the absence of diseases.