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Module 3 - Hepatic & Lipid Tests Flashcards

1
Q

What are some functions of the liver?

A
  • cholesterol synthesis and excretion
  • removal of old RBCs
  • activation of vitamin D
  • detoxification and metabolism
  • synthesis of proteins and clotting factors (albumin, INR)
  • processes nutrients
  • storage (glycogen, fats, iron, copper, vitamins)
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2
Q

What are considered “synthesis tests”?

A
  • INR

- albumin

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3
Q

What are considered “cholestatic tests”?

A
  • ALP
  • GGT
  • Bilirubin (conjugated)
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4
Q

What are considered “hepatocellular damage tests”?

A
  • AST/ALT
  • LDH
  • Bilirubin (total)
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5
Q

What are LFTs?

A

liver function tests

*not really accurate since many of the tests included in a LFT panel don’t measure function, they measure damage

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6
Q

_____ is responsible for producing clotting factors

A

Liver

*If liver is substantially diseased (>80% loss of function) clotting factors are dysfunctional or l=not produced

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7
Q

Abnormal clotting factors = _______ INR

A

increased

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8
Q

What things can increase INR?

A
  • warfarin
  • antibiotics (decreased vitamin K production in gut)
  • malabsorption of vitamin K
  • genetic clotting factor deficiencies
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9
Q

______ is a protein synthesized from amino acids in the liver

A

Albumin

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10
Q

What is albumin important for?

A
  • maintaining osmotic pressure in the blood (albumin expands blood volume)
  • transport of hormones, drugs, fatty acids and ions
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11
Q

Half life of albumin?

A

Long half-life (20 days)

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12
Q

Possible reasons for albumin to be low?

A
  • malnutrition
  • loss in the urine (kidney disease)
  • severe burns
  • large amounts of fluid administration (dilution)
  • pregnancy (dilution)
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13
Q

Bilirubin metabolism:

Starts off with ?

A

Breakdown of RBCs

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14
Q

Bilirubin metabolism:

Hemoglobin converted to bilirubin in _____

A

spleen

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15
Q

Bilirubin metabolism:

Liver makes bilirubin ______ ______

A

water soluble (direct or conjugated bilirubin)

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16
Q

Bilirubin metabolism:

_____ bilirubin is excreted into the bile

A

Conjugated

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17
Q

Bilirubin metabolism:

Conjugated bilirubin ends up in the ______ to be excreted in stool (brown color)

A

intestines

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18
Q

Bilirubin metabolism:

If there is a blockage in the bile duct (cholestastis), conjugated bilirubin can be found in the _____

A

urine

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19
Q

Direct bilirubin = ______

A

soluble (in water)

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20
Q

Indirect bilirubin = _______

A

insoluble

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21
Q

Should direct/conjugated bilirubin be in the blood?

A

NO WAY

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22
Q

What does an elevated direct bilirubin level indicate?

A

that something is preventing bile flow to the intestines
**liver is working (conjugating) but it can’t get rid of the water-soluble bilirubin due to obstruction or damaged liver cells

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23
Q

What are potential causes of having increased levels of direct bilirubin?

A
  • obstruction of the bile duct
  • intrahepatic cholestasis
  • hepatitis
  • toxins
  • cirrhosis
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24
Q

What is ALP?

A 
Alkaline Phosphatase (ALP)
-A group of isoenzymes that remove phosphate groups from molecules (exact function of these isoenzymes still being discovered)
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25
Q

ALP:

____% in liver and bone

A

80

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26
Q

ALP:

___% in the intestine

A

20

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27
Q

What types of people may have an elevated ALP?

A
  • children and adolescents have higher ALP due to bone development
  • pregnancy (placental ALP)
  • elevated in bone disorders (i.e. fractures, cancers)
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28
Q

ALP is also elevated in pts with _______ disease

A

cholestatic

*bile accumulation = increased ALP synthesis

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29
Q

How long does it take for ALP to be elevated in patients with cholestatic disease?

A

4-6 weeks for elevation to occur (SLOW)

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30
Q

Once obstruction is resolved, ALP returns to normal in _____ weeks

A

2-4

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31
Q

Since ALP is a non-specific test, what do you need to interpret it with?

A

GGT

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32
Q

What is GGT?

A

Gamma-Glutamyl Transferase

-enzyme that carries gamm-glutamyl functional groups

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33
Q

GGT is ______ for cholestatic disorders but not ______.

A

it is sensitive but not specific

good for ruling out cholestasis but not good for ruling it in

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34
Q

GGT may be elevated after an _____ ______

A

myocardial infarction

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35
Q

GGT is strongly associated with ?

A

alcoholic liver disease

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36
Q

GGT/ALP ratio > 2.5 is indicative of what?

A

ethanol abuse

37
Q

Abstinence from alcohol can reduce GGT by ___% in 2 weeks

38
Q

List a few drugs that can cause cholestasis

A
  • NSAIDs
  • oral contraceptives
  • B-lactams
  • amiodarone
  • more on slide 16
39
Q

ALT converts what?

A

alanine to glutamate

40
Q

AST converts what?

A

aspartate to glutamate

41
Q

Describe AST

A

Aspartate Transaminase (AST):

  • found in liver as well as heart, skeletal muscle, kidneys, brain, pancreas, spleen, lungs and RBCs
  • less specific to the liver than ALT
  • half life of 17 hours
42
Q

Describe ALT

A

Alanine Transaminase:

  • More specific to the liver than AST (but can still be found in other tissues such as kidneys, heart, muscle and pancreas)
  • Half life of 47 hours
43
Q

AST & ALT are generally higher in the _______

44
Q

Vigorous exercise can ______ AST/ALT (muscle breakdown)

45
Q

Dialysis can _____ AST/ALT levels

46
Q

Transaminase levels don’t correlate with disease _______

47
Q

Most of bilirubin is ______

A

unconjugated

48
Q

Why might total bilirubin be elevated in hepatocellular injury?

A

hepatocyte damage = decreased bile production/flow

49
Q

Symptoms of hyperbilirubinemia?

A
  • jaundice
  • pruritus
  • xanthomas (lipid deposits in skin)
50
Q

In premature babies, high bilirubin can cause _____

A

kernicterus

51
Q

What is kernicterus ?

A

rapid RBC breakdown - BBB not formed + liver enzymes not formed = bilirubin buildup in the brain = DAMAGE

52
Q

What is LDH?

A

Lactate dehydrogenase:

-an enzyme responsible for converting lactate to pyruvate (and vice versa) in anaerobic metabolism

53
Q

Why is LDH not really that clinically useful?

A

it is non-specific to the liver

54
Q

What may LDH be helpful in differentiating?

A

Causes of acute liver injury

55
Q

ALT/LDH ratio > 1.5 = ?

A

viral hepatitis

56
Q

ALT/LDH ratio < 1.5 = ?

A

ischemic hepatitis or acetaminophen toxicity

57
Q

What are some signs and symptoms of hepatic injury/disease?

A
  • right upper quadrant pain
  • jaundice
  • pruritus
  • ascites (fluid accumulation in peritoneal cavity)
  • malaise/fatigue
  • malnutrition/anorexia/muscle wasting
58
Q

What test results would indicate cholestasis?

A 
increased ALP
AND
increased GGT
AND
increased conjugated bilirubin
59
Q

What test results would indicate hepatoceullar injury?

A 
increased AST/ALT 
AND/OR
increased bilirubin
AND/OR 
increased LDH
60
Q

What does idiosyncratic mean?

A

not dose-related

61
Q

What are examples of idiosyncratic causes (not dose-related)?

A

Allergic reaction
Bile duct injury
Hepatocellular injury

62
Q

What are examples of drugs that can cause dose-related hepatotoxicity?

A
  • TYLENOL MAN

- Also cocaine and meth

63
Q

LDL = _____

64
Q

HDL = _____

65
Q

LDL formula

A

LDL = total cholesterol - HDL - (TGs/2.2)

66
Q

If TGs are too high (> 4.5 mmol/L) LDL is _____

A

inaccurate

67
Q

What does HDL do?

A

scavenges cholesterol out of vessels and tissues

68
Q

After eating, TGs appear in plasma ____ hrs after a meal and peak in _____ hours and can persist for up to 14 hours

A

2 hrs

4-6 hrs

69
Q

What type of patients have high TGs?

A
  • diabetes
  • kidney disease
  • obesity
  • liver disease/alcoholism
70
Q

What type of medications can increase TG and LDL levels?

A

steroids, antipsychotics, thiazide diuretics

71
Q

For most patients, LDL target is ??

A

50% reduction or < 2 mmol/L

72
Q

What is CK?

A

Creatine Kinase:

-enzyme that stimulates transfer of high-energy phosphate groups

73
Q

CK can be used as a marker for what?

A

muscle injury/death (MI, myopathies)

74
Q

What type of people can have elevated CK?

A

marathon runners or people who do intense physical activity

75
Q

What is a myopathy?

A

A general term referring to any muscle disease

*CK levels N/A

76
Q

What is myalgia?

A

Muscle pain or weakness

*CK levels normal

77
Q

What is myositis?

A

A myalgia with increased CK levels

*Increased but <10x ULN

78
Q

What is rhabdomyolysis?

A

Muscle symptoms with marked CK elevation and renal symptoms (creatinine elevation)
*CK levels > 10-25x ULN with renal symptoms

79
Q

When should CK decline if you stop a statin and that was the cause of the muscle pain?

A

in 3-4 days

80
Q

What lipid ab tests do you order when a pt is on statin?

**THIS IS DIFFERENT FROM WHAT WE LEARNED IN CLINICAL

A

TC, LDL, HDL, TC/HDL, TG

81
Q

When do you order these lipid lab tests when on a statin?

A

Baseline, 6-8 weeks after initiation, then every 6 months

82
Q

What lab tests do you order for liver injury?

83
Q

When do you order liver injury lab tests?

A

Baseline, then only if symptoms are present

84
Q

If AST/ALT > ____ ULN consider stopping statin

85
Q

What lab tests do you order for muscle injury when on statin?

86
Q

When do you order muscle injury lab tests?

A

Baseline, then only if symptoms present

87
Q

If CK > ____ ULN then STOP statin. When resolved, decrease dose or switch statin

88
Q

If CK < 10x ULN, what do you do?

A

continue but lower statin dose

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