Assessment of liver dysfunction

For updates on diagnosis and management of coexisting conditions during the pandemic, see our topic 'Management of coexisting conditions in the context of COVID-19'.

Serum liver chemistry tests, commonly called liver tests, or (mistakenly) liver function tests, are ordered for many reasons. Most laboratories offer these tests as a bundle, and this usually includes:

• Bilirubin (breakdown product of the RBC after conjugation in the liver and secretion in biliary system excretion)

• Alanine aminotransferase (ALT)

• Alkaline phosphatase (ALP)

• Serum albumin.

The following tests may also be included in this bundle:

• Aspartate aminotransferase (AST)

• Gamma glutamyl transferase (gamma-GT)

• Lactate dehydrogenase (LDH).

Individual tests in these panels are not specific for liver disease. Therefore, pattern recognition is critical. Assessment of patients with abnormal liver tests should be guided by history, risk for liver disease, duration and severity of clinical findings, presence of comorbidities, and the nature of the liver test abnormality noted.

Traditionally, liver tests abnormalities have been grouped under the following patterns:[1]Kwo PY, Cohen SM, Lim JK. ACG clinical guideline: evaluation of abnormal liver chemistries. Am J Gastroenterol. 2017 Jan;112(1):18-35. http://www.ncbi.nlm.nih.gov/pubmed/27995906?tool=bestpractice.com

• Hepatocellular (predominantly ALT and AST elevations)

• Cholestatic (predominantly ALP elevation)

• Mixed/infiltrative (elevation of both ALT/AST and ALP).

Isolated elevation of liver tests is a less common occurrence in liver diseases, and a non-hepatic source should also be considered in such instances. Bilirubin may be elevated in any category of liver disease.[2]Murali AR, Carey WD. Liver test interpretation - approach to the patient with liver disease: a guide to commonly used liver tests. April 2014 [internet publication]. http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/hepatology/guide-to-common-liver-tests Isolated gamma-GT elevations are so common and so often unhelpful that many institutions have chosen to delete this test from their liver test panel.[3]Carey WD. How should a patient with an isolated GGT elevation be evaluated? Cleve Clin J Med. 2000 May;67(5):315-6. http://www.ncbi.nlm.nih.gov/pubmed/10832186?tool=bestpractice.com When other liver tests are abnormal, categorisation according to pattern is helpful to determine the probable aetiology.

Clinical correlation is essential when interpreting liver tests. Liver tests are abnormally elevated in 1% to 9% of the asymptomatic population.[4]Malakouti M, Kataria A, Ali SK, et al. Elevated liver enzymes in asymptomatic patients - what should I do? J Clin Transl Hepatol. 2017 Dec 28;5(4):394-403. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5719197 http://www.ncbi.nlm.nih.gov/pubmed/29226106?tool=bestpractice.com Further investigations with diagnostic serology and liver biopsy are normal in 6% of these patients.[5]Skelly MM, James PD, Ryder SD. Findings on liver biopsy to investigate abnormal liver function tests in the absence of diagnostic serology. J Hepatol. 2001 Aug;35(2):195-9. http://www.ncbi.nlm.nih.gov/pubmed/11580141?tool=bestpractice.com Importantly, people with chronic liver disease or cirrhosis may have normal liver tests.[6]Ahmed Z, Ahmed U, Walayat S, et al. Liver function tests in identifying patients with liver disease. Clin Exp Gastroenterol. 2018 Aug 23;11:301-7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6112813 http://www.ncbi.nlm.nih.gov/pubmed/30197529?tool=bestpractice.com [7]Bacon BR. Treatment of patients with hepatitis C and normal serum aminotransferase levels. Hepatology. 2002 Nov;36(5 Suppl 1):S179-84. https://aasldpubs.onlinelibrary.wiley.com/doi/epdf/10.1053/jhep.2002.36386 http://www.ncbi.nlm.nih.gov/pubmed/12407592?tool=bestpractice.com

Liver tests are markers of liver injury, not liver function.[1]Kwo PY, Cohen SM, Lim JK. ACG clinical guideline: evaluation of abnormal liver chemistries. Am J Gastroenterol. 2017 Jan;112(1):18-35. http://www.ncbi.nlm.nih.gov/pubmed/27995906?tool=bestpractice.com Functional assessment of the liver (evaluating protein synthesis, metabolism, bile production, storage, and detoxification) can be determined by:

• Conventional liver tests such as albumin and INR

• Scoring systems such as Model for End-Stage Liver Disease (MELD) and Child-Turcotte-Pugh (CTP) score, based on laboratory test results and clinical features.