Liver & Kidney Function

Tests.
Dr. Samer El-Daher
University of Greenwich.

Announcement from Paul Dyer.

Please make note of the following:
Lab Group 5

Tuesday 23rd Feb 10:00-13:00 Histology

Tuesday 23rd Feb 14:00-17:00 Haemoglobin practical
Tuesday 9th March 10:00-13:00 Microbiology Identification

Lab Group 6 & 7

Tuesday 2nd Mar 10:00-13:00 Histology

Tuesday 2nd Mar 14:00-17:00 Haemoglobin practical
Tuesday 9th March 14:00-17:00 Microbiology Identification

Lecture Outline
Overview of structure and function of the liver

and the kidney.

Overview of some diseases that can affect
liver and kidney.
The common biochemical tests for each of
these organs
The diagnostic role of these common tests.

Separation of Blood.
The formed elements

can be separated from

plasma by
centrifugation,
components separate
according to their
densities.

Structure of the Liver.

Structure of the Liver.

Average weight in adults is 1500g.
The liver is organised into 4 lobes, left, right,

quadrate and caudate.

Blood enters via the hepatic artery and the portal vein
bringing blood rich in nutrients from the gut.
Blood then passes across a large surface area of
hepatocytes which excrete bile into the bile canaliculi.
Blood leaves via hepatic vein.

Hepatocytes are covered in receptors that allow

efficient removal of substances from the blood

stream.
The left and right hepatic ducts carry bile to the gall
bladder.
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Function of the Liver.

The liver regulates levels of most chemical in the

blood.
Excretes bile, which helps carry away waste products
from the liver.
All the blood leaving the stomach and intestines
passes through the liver.
In the liver this blood is processed.
It breaks down the nutrients and drugs into forms that
are easier to use for the rest of the body.
More than 500 vital functions have been identified
with the liver.
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Some Functions of Liver.

The liver is considered as an organ that deals with

processing, transport and storage, some important

functions are:

Glucose/carbohydrate metabolism.
Protein metabolism.
Lipid metabolism.
Fat metabolism.
Ammonia conversion.
Vitamin and iron storage.
Drug metabolism.
Bile formation metabolism.
Storage of metabolites.
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Common Liver Function Tests.

In a clinical Biochemistry laboratory routine tests,

front-line or follow up, for assessment of liver

function, these involve measuring:

Bilirubin.
Liver enzymes
Transaminases.
Alkaline phosphatase.
Albumin.
Bile Acids.
Ammonia.
Specific proteins; 1-antitrypsin, -foetoprotein &
coagulation factors.
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Liver Diseases.
Liver is vulnerable to many diseases caused by metabolic,

viral, microbial, circulatory & neoplastic injuries.

The damage caused usually takes a long time to manifest
itself as a disease with clinical symptoms.
Liver diseases can be classified according to the
biochemical changes that occur, they can be divided into;
Hepatocellular
Diseases that cause damage to the hepatocytes
usually due to viral infections and drugs.
Cholestatic due to cholestasis
Cholestasis, blockage in the biliary tree causing
impairment to bile flow through the canaliculi into the
gut.

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Patterns of Hepatic Injury.

Fibrosis
Fibrous tissue formed in response to toxic insult or
inflammation / irreversible damage.
Degeneration and intracellular accumulation

Fat, Iron, Cupper accumulation in liver cells.

Necrosis and apoptosis

Apoptotic cell death and coagulative & liquefaction
necrosis.
Inflammation

Influx of acute or chronic inflammatory cells (Hepatitis).

Regeneration
Response to tissue resection and cell death
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Liver Function Tests.

Bilirubin
Conjugated, unconjugated and free.
The tests performed is usually direct & indirect
bilirubin.
Total bilirubin is measured by reacting with alkaline

sulphanilic acid, Jendrassik-Grof method.

Only conjucated bilirubin reacts in absence of an
accelerator, direct-reacting bilirubin, therefore called
direct bilirubin.
In the presence of accelerator, a caffeine-benzoate
reagent, unconjugated bilirubin reacts, indirect
bilirubin.
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Bilirubin
Bilirubin is a yellow compound formed from the

breakdown of haemoglobin, resulting from the

breakdown of old and damaged RBCs in the spleen.
Albumin binds to bilirubin and transport it to the liver
where it is metabolised in liver by conjucation with
glucoronic acid.
Conjucated bilirubin is water soluble and is secreted
into the bile canaliculi.
In the gut bacteria will reduce it to urobilinogen.
90% is then secreted in faeces and the rest will be
secreted in the urine.
When liver cannot process bilirubin its concentration
will increase in the blood, indicating a liver disease.
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Bilirubin & Jaundice.

14

Jaundice
Jaundice is a yellowish discoloration of the

skin and of the whites of the eyes caused by

abnormally high levels of the bilirubin in the
bloodstream.

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Liver Function Tests.

Transaminases are enzymes found inside

hepatocytes.
If cells are damaged they will be released into
the blood stream, can be measured and
levels are used to assess liver disease.
The two activities that are routinely assessed
for liver function are:
Aspartate aminotransferase, AST
Alanine aminotrasferase, ALT, more specific.

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ALT
Used for identification of inflammation and

necrosis of the liver.

Located in the microsomal portion of the
hepatic cell in contrast to AST which is
located in the mitochondria.
If level > 20 times reference range , indicate
hepatic injury
High in acute viral hepatitis level exceeds that
of AST.
Reference range, 3-55 IU/L.
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AST.
Usually high in cases of alcohol induced liver

cell mitochondrial necrosis.

Not greatly affected by viral infection of the
liver.
Increased level indicates acute abnormality of
liver, heart and/or skeletal muscles.
Level higher than ALT in liver necrosis such
as alcoholic hepatitis.
Reference range, 12-48 IU/L.
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Liver Function Tests. ALP

Another very important enzyme is Alkaline Phosphatase,

ALP.
Present in liver canalicular and sinusoidal membranes.
Level increases in liver damage usually due to
cholestasis
In cholestatic jaundice level is 4-6 X reference range
(80-280 IU/L).
Test complicated by presence of isoforms in other
tissues, bone, kidney and placenta.
Then need to combine this test with -GT, if both raised
then its due to liver damage.
This can be then confirmed by electrophoresis of liver
isoforms.
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Liver Function Tests.

-glutamyltransferase, GT, found in many

tissues. Reference range <36 IU/L.

Its level increases in cholestasis together with
ALP.
Drugs and alcohol induce GT activity .
If ALP is normal and GT is raised it could be
an indication of the individual alcohol level
consumption.
In many cases this activity is used as a
screen for alcohol intake.
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Liver Function Tests.

Albumin. A circulatory transport protein manufactured

in the liver.
The most abundant protein in circulation.
It is used mainly as a marker for the synthetic
function of the liver.
It has a long half-life, therefore reduced levels in the
serum indicate a long term problem.
If level is reduced, hypoalbuminaemea, is a strong
indication of advanced chronic liver disease.
Reference value, 40-52 g/L.
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Specialised Liver Tests.

-Foetoprotein. Reference value <20g/L
A protein synthesised by foetal liver cells, if present in
adults it is an indication of hepatocellular carcinoma.
Also an indication of hepatitis and chronic liver
diseases.
Ceaurloplasmin. 200-600 mg/L

Low levels indicate Wilsons disease

Other specialised test include:

Viral markers, auto-antibodies/mitochondrial
antibodies.
Arterial blood ketone body ratio.
Carbohydrate antigen 19-9.
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The Kidney.
A secretory organ.
Contains millions of filtration units, the functional

units, nephrons.
They filter blood and produce urine that contains
waste products.
Precisely regulate body concentration of:

Water & salt.

Maintain acid base balance of plasma.
Endocrine activity, secrete erythropoietin, renin and
prostaglandines.

Excrete all waste products resulting from metabolism.

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Structure of the Kidney.

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Pathology.
Kidney diseases are very complex but can be divided

into diseases affecting 4 main components:

Glomeruli,
Tubules,
Interstitium,
And blood vessels.

Components are more susceptible to different factors

affecting them;

Glumerular diseases seem to originate from

immunological agents, while
Tubular and intestinal are caused by toxins and
infectious agents.
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Clinical Manifestations.
Acute nephritic syndrome;

Affects glomeruli with visible hematuria, RBCs

in urine.
Protenuria mild-moderate and hypertension.

Nephrotic syndrome;

Heavy protenuria > 3.5mg/L, lipiduria,

hypoalbuminemia.

Asymptomatic hematuria or proteinuria,

Manifestation of mild glomerular abnormalities.

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Urine colour/appearance

Urine may also be clear, bloody,

cloudy or flocculent (big bits in it).
Increasing concentration of urine
www.medaille.edu

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Kidney Function Tests.

Routinely the following test are performed to

evaluate kidney function:

Blood urea nitrogen (BUN).
Creatinine.
Uric acid.
Sodium.
Potassium.
Chloride.
Bicarbonate.

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Blood Urea Nitrogen (BUN).

Urea is the major end product of protein

metabolism, generated in the liver by the urea

cycle then excreted by the kidney.
Urea concentrations in the serum can vary
widely in healthy volunteers, due to dietary
intake and state of hydration.
Usually not significantly increase until
glomerular filtration is reduced to about 50%.
Reference value, 7-21 mg/dl
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Creatinine.
Creatinine is formed by dehydration of muscle

phosphocreatine, direct relation to muscle mass.

Freely filtered by glomeruli and under normal
conditions not reabsorbed.
Measurement are an indication of glomeruli filtration
and can be used as an indication of renal function.
More reliable than urea test as it is not dependent on
hydration state or dietary protein intake.
Reference range, 0.5-1.4 mg/dl

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Sodium.
Re-absorption regulated by aldosterone.
Most re-absorption 60-70% takes place in the

proximal tubules, with 25-30% in the ascending loop

of Henle.
In the distal tubules regulation of sodium
concentration occurs, it is coupled to the exchange of
potassium and/or hydrogen.
This determines how much Na is secreted in the
urine.

Hypernatremia can be caused by excess water loss.

Hyponatremia may be caused by decrease of tubular reabsorption as a result of primary or secondary
hypoaldosteronism
Reference value, 137-145 mEq/L
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Potassium.
Potassium is reabsorbed in proximal tubules

and ascending loop of Henle, about 90%.

10% of filtered load reaches the distal tubule
where as stated before it is regulated by
aldosterone and is secreted in exchange for
sodium.
Reference value, 3.6-5.0 mEq/L

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Urinanalysis - Appearance
Blood (haematuria)

Check with Dipstix (blood, sugar, protein).

Simple, cheap, routine, easy to re-check and unlikely to
make mistakes. But not quantifiable, just checks for
presence.
Patient would probably know about it as it hurts.
Very concentrated dark/smoky colour.
Very clear urine with high frequency of urination indicates its
less likely to be a bacterial problem.
Discoloration may also be due to:
Jaundice, haemoglobinuria.
Drugs (e.g. antibiotics).
Food (e.g. beetroot).
Disease (e.g. porphyria, Madness of King George, urine
turns purple)

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Urinanalysis - Volume
Temperate climates: output of 800-2500 ml urine per day

is usual.
Dependent upon subjects activity, hydration status, diet
and body size.
Always need to urinate to get rid of metabolic wastes,
even if not drinking. Remember that you can urinate to
death if you are shipwrecked either through lack of
water, or by ingestion of salt water!
Sudden changes in volume of urine can indicate
problems with ability to concentrate urine, or in feedback
mechanisms that help you control ECF
volume/osmolality.

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Urinanalysis
Oligouria excrete < 300 ml/day.
Might be physiological as in hypotension or hypovolaemia where we
compensate, but more often due to renal disease or obstructive
nephropathy.
Polyuria persistent, large increase in urine output associated with

nocturia.

Must distinguish from higher frequency of small volumes of urine.

Usually due to hysterical intake of water, increased excretion of solute
(e.g. hyperglycaemia/glycosuria), defect in concentrating ability or ADH
failure).

Osmolality useful for determining whether ionic imbalances exist in

subject.

May indicate renal failure (e.g. excess urea) or problems with ADH.

Urinary pH mainly for acidosis/alkalosis determination important

when studying metabolism of various nutrients e.g. glucose during

exercise

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Chemical (Stix) testing

Blood very sensitive 2 or more cells can produce result.
Sometimes TOO sensitive, giving false positives.
Cant distinguish between blood and free Hb, so usually double-check
with microscope.
Protein
Strips detect 100 mg/l or more in urine react with albumin.
Check throughout 24 hr period
Some protein always excreted, but can be falsely increased by
exercise, growth, fever etc.
Time of day taken lying down causes protein to settle and its not
detected in urine.
Glucose
Positive test can mean diabetes mellitus.
Have to exclude ingestion of high sugar diet.
Now a really easy, cheap, sensitive, routine way of testing subjects, but

not good enough on its own and not quantitative.

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Dipstix

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Urine Microscopy
Clean, mid-stream sample needed.
White cells

10 or more WBCs per cm3 indicates inflammation (e.g.

urinary tract infection (UTI))
Red cells again, subject may be aware of it already via pain.
Casts
Cylindrical bodies made from precipitated proteins, often
seen normally after exercise.
Red cell casts (even one) always means disease.
Bacteria allows you to decide which antibiotic is best for
subject. Checking for blood/urine not always good for checking
for infections, since these subjects can have completely clear
urine.

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Blood values indirect indicators of

renal function
If there is poor renal function, you might expect any one of:
Hyperkalaemia
Decreased bicarbonate poor filtration or acid/base disorders
Elevated urea
Elevated creatinine
Elevated uric acid
Hypocalcaemia
Hyperphosphataemia
pH acid/base disorders
pCO2 away from 40mmHg acid/base disorders
Hypernatraemia
These are the most common plasma constituents we would measure if we

were analysing renal function in the lab.

Cheap, easy, routinely done, and provide a large amount of information
quickly.

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Quantitative tests of renal function

Commonly used imaging techniques include:

Plain X-ray
Cystoscopy
Excretion urography
Ultrasonography
Computed tomography (CT)
Magnetic resonance imaging (MRI)

Antegrade pyelography
Retrograde pyelography
Micturating cystourethrography (MCU)

Aortography or renal arteriography

Renal scintigraphy dynamic and static
Transcutaneous renal biopsy
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