Prescribing in Liver Impairment Flashcards

1
Q

What are the different types of liver disease?

A

Hepatitis
Alcohol-associated liver disease
Alcohol-associated fatty liver
Alcohol-associated hepatitis
Alcohol-associated cirrhosis
Non-alcoholic fatty liver disease (NAFLD)
Non-alcoholic steatohepatitis (NASH) –

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2
Q

What is hepatitis?

A

inflammation of the liver caused by viruses (A, B, C) or autoimmune.

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3
Q

What are the stages of alcohol-associated liver disease?

A
  1. Alcohol-associated fatty liver – early stages of alcoholic liver disease caused by extensive damage to liver cells by excessive alcohol intake.
  2. Alcohol-associated hepatitis – further damage of liver cells and inflammation of tissue caused by continuing to drink.
  3. Alcohol-associated cirrhosis – most
    serious form where the extent of damage to the liver by alcohol causes development of scar tissue, which significantly impacts hepatic function.
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4
Q

What is NAFLD?

A

Liver disease caused by excess fat in the liver which leads to inflammation.

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5
Q

What is non-alcoholic steatohepatitis?

A

A form of NALD where there is inflammation and cell damage in the liver as well as fat. This can develop into cirrhosis.

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6
Q

What is used to assess the severity of liver cirrhosis?

A

Child-Pugh score

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7
Q

What does the Child-Pugh score consider?

A

Ascites
Bilirubin
Albumin
Prothrombin time or INR
Encephalopathy

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8
Q

What is ascites?

A

Collection of fluid in the abdomen caused by liver cirrhosis due to high pressure in certain veins of the liver (portal hypertension) and low serum albumin.

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9
Q

What does the Child-Pugh score indicate?

A

Cirrhosis classification:
5-6: Class A – well-compensated disease, 100% 1-year survival, 85% 2 year survival

7-9: Class B – significant functional compromise. 80% 1-year survival, 60% 2-year survival.

10-15: Class C – decompensated disease. 45% 1-year survival, 35% 2-year survival

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10
Q

What do ALT and AST tests indicate?

A

They are intracellular enzymes which care released from hepatocytes when they become damaged. Therefore, high serum levels indicate hepatocellular injury.

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11
Q

What does the AST:ALT ratio indicate and why?

A

The AST: ALT ratio can indicate the progression of liver disease. ALT is more specific to the liver with small concentrations in other organs, AST is found highly in the liver, heart, pancreas, lungs, muscles and RBC.
A high ALT alone indicates acute injury, but if long-term liver disease/damage occurs, it will affect other organs and raise AST also. An AST:ALT of 1:2 indicates non-alcoholic liver disease, but 2:1 indicates alcoholic liver disease.

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12
Q

What do ALP tests indicate?

A

Detects cholestasis – if the flow of bile is obstructed (e.g., by a gallstone), serum ALP will increase.

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13
Q

Why must ALP be used in conjunction with other LFTs?

A

Any condition affecting bone growth or causes increased activity of bone cells can affect ALP, so not specific.

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14
Q

What does raised GGT with raised ALP or bilirubin suggest?

A

Cholestatic damage

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15
Q

What does isolated raised GGT indicate?

A

Hepatic damage caused by:
Alcohol abuse
Enzyme inducing drugs

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16
Q

What does raised GGT in patients with chronic liver disease indicate?

A

Bile duct damage
FIbrosis

17
Q

Why can GGT only be used in conjunction with other LFTs?

A

Released in all types of liver dysfunction.

18
Q

What do bilirubin levels incidicate in LFTs?

A

Bilirubin is a pigment produced by the destruction of red blood cells. Hepatocytes transform unconjugated bilirubin into water-soluble conjugated form which is excreted via bile into the intestine. High levels of bilirubin (50micromol/L serum) can produce jaundice. This may be due to hepatic damage reducing metabolism of unconjugated to conjugated bilirubin, causing hyperbilirubinaemia.

19
Q

Why should bilirubin levels be assessed in conjunction with other LFTs?

A

High bilirubin can be caused by excess release due to haemolytic anaemia. Consult other LFTs and whether or not the bilirubin is conjugated (HA) or unconjugated (LD).

20
Q

What do albumin levels indicate in LFTs?

A

Albumin is a plasma protein produced by the liver which governs oncotic pressure. Albumin is a hepatocellular marker as low levels can indicate reduced liver function. Its long half-life means it is an indicator of chronic rather than acute liver disease.

21
Q

Other than impaired liver function, what else can decrease albumin levels?

A

Reduced production - malnutrition, malignancy
Increase loss - IBD, nephoritic syndrome

22
Q

Why is a clotting screen (INR and PT) performed in LFTs?

A

The liver is responsible for production of vitamin-K dependent clotting factors. If a patient is given a dose of vitamin K and the INR doesn’t decrease, this may indicates the synthetic function of the liver has decreased.

23
Q

Why is a clotting screen used in conjunction with other LFTs?

A

It is non-specific as low INR following vitamin K may also indicate vitamin K absorption is impaired, the patient has a coagulopathy disorder, or is on warfarin.

24
Q

What are some key medicines which can result in acute liver damage or cholestasis? (12)

A
  • Amiodarone
  • Azathioprine
  • Carbamazepine
  • Isoniazid
  • Methotrexate
  • NSAIDs
  • Antibiotics such as co-amoxiclav and flucloxacillin
  • Paracetamol
  • Rifampicin
  • Sodium valproate
  • Statins
25
Q
A