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Liver function evaluation

1. Detoxification & Excretory function¿¡ ±Ù°ÅÇÑ °Ë»ç

1) serum bilirubin

- van den Bergh assay : direct(=conjugated), indirect(=unconjugated)

- unconjugated bilirubinÀº albumin°ú °áÇÕÇÑ »óÅ·ΠÁ¸ÀçÇÏ¸ç ºÒ¿ë¼º(water-insoluble)À¸·Î

½ÅÀåÀ¸·Î ¹è¼³µÇÁö ¸øÇÑ´Ù.

unconjugated bilirubinÀÇ Áõ°¡´Â °£Áúȯ¿¡¼­´Â µå¹É¸ç ´Üµ¶À¸·Î »ó½ÂÇÒ °æ¿ì ÀÏÂ÷Àû

À¸·Î´Â hemolytic disorder¸¦ ÀǽÉÇÏ°í ±× ¿Ü Crigler-Najjar syndrome, Gilbert syndrome

°°Àº À¯Àü¼º ÁúȯÀ» ÀǽÉÇÒ¼ö ÀÖ´Ù.

cf. Gilbert's syndrome: ÈçÇÑ ¾ç¼ºÁúȯÀÌ´Ù(3-7%).

UDP-GT(Uridine diphosphate glucuronosyl transferase) activity°¨¼Ò·Î

conjugation¿¡ Àå¾Ö°¡ »ý°Ü mild unconjugated hyperbilirubinemiaÀ¯¹ß

- conjugated bilirubinÀº ¼ö¿ë¼ºÀ¸·Î ½ÅÀåÀ¸·Î ¹èÃâµÈ´Ù.

¨ç Isolated unconjugated hyperbilirubinemia (Direct<15%)

Áï½Ã hemolysis¿¡ ´ëÇÑ work-upÀ» ½ÃÇàÇϰí

hemolysis°¡ ¾ø´Ù¸é Gilbert's syndromeÀ¸·Î »ý°¢ÇÏ°í ´õ ÀÌ»óÀÇ Á¶»ç´Â ÇÊ¿ä¾ø´Ù.

¨è Conjugated hyperbilirubinemia

Ç×»ó liver or biliary disorder¸¦ ÀǹÌÇÏ¸ç ´ëºÎºÐÀÇ °£Áúȯ¿¡¼­´Â

µÑ´Ù(conjugated & unconjugated) Áõ°¡ÇÑ´Ù.

* Alb-bilirubin complexÀÇ ¹Ý°¨±â(15ÀÏ)´Â conjugated bilirubinº¸´Ù ÈξÀ ±æ´Ù.

2) urine bilirubin

urine¿¡¼­ bilirubinÀÌ °ËÃâµÇ¸é ÀÌ´Â Ç×»ó conjugated bilirubinÀ̸ç bilirubinuriaÀÇ Á¸Àç´Â

°£ÁúȯÀÌ ÀÖÀ½À» ÀǹÌÇÑ´Ù.

urine dipstick test´Â 100% Á¤È®ÇÏ´Ù.

3) Blood ammonia - poor correlation

4) serum enzyme

* 3 categories

i) hepatocyte damage¸¦ ¹Ý¿µÇÏ´Â °Í

ii) cholestasis¸¦ ¹Ý¿µÇÏ´Â °Í

iii) ¾î´À°Íµµ ¾Æ´Ñ °Í

i) hepatocyte damage¸¦ ¹Ý¿µÇÏ´Â È¿¼Ò

AST/ALT : sensitive indicator

AST - liver, heart, muscle µî¿¡¼­ ¹ß°ß

ALT - liver¿¡¼­ ÁÖ·Î ¹ß°ß

°£¼¼Æ÷¸· ¼Õ»óÀÌ ÀÖÀ» ¶§ Åõ°ú¼ºÀÌ Áõ°¡µÇ¾î Ç÷ÁßÀ¸·Î ¸¹Àº¾çÀÌ ¹æÃâµÈ´Ù.

È¿¼Ò ¹æÃâÀ» À§ÇØ ¹Ýµå½Ã liver cell necrosisµÉ ÇÊ¿ä´Â ¾øÀ¸¸ç liver cell damageÁ¤µµ¿Í

AST/ALT ¼öÄ¡»çÀÌÀÇ »ó°ü°ü°èµµ ¾ø´Ù.

±×·¯¹Ç·Î AST/ALTÀÇ Áõ°¡°¡ acute hepatocellular disorderÀÇ ¿¹ÈÄ¿¡ Áß¿äÄ¡ ¾Ê´Ù.

ÁߵÀÇ »ó½Â(300 U/L) - ºñƯÀÌÀûÀÌ¸ç ¾îµð¼­³ª º¼¼ö ÀÖ´Ù.

1000 U/L¡è - extensive hepatocellular injury¿Í °ü·Ã

i) viral hepatitis

ii) ischemic liver injury(prolonged hypotension or acute heart failure)

iii) toxin or drug-induced liver injury

´ëºÎºÐÀÇ acute hepatocellular disorder¿¡¼± ALT°¡ ASTº¸´Ù ´õ ³ô´Ù.

AST/ALT > 2ÀÏ ¶§´Â alcoholic liver disease¸¦ ÀǹÌÇÑ´Ù.

( >2 : suggestive, >3 highly suggestive )

ALT 300 ÀÌ»óÀº µå¹°¸ç ALT´Â ÈçÈ÷ Á¤»óÀÌ´Ù. ALT levelÀÌ ³·Àº ÀÌÀ¯´Â alcohol¿¡ ÀÇÇØ

pyridoxal phosphate°áÇÌÀÌ »ý±â±â ¶§¹®ÀÌ´Ù.

ii) cholestasis¸¦ ¹Ý¿µÇÏ´Â È¿¼Ò - ALP, 5-N, GGT

ALP, 5-N : bile canalicular membraneÀ̳ª ±Ùó¿¡¼­ ¹ß°ß

GGT : bile duct epitheliumÀÇ endoplasmic reticulum¿¡¼­ ¹ß°ß

GGTÀÇ Áõ°¡´Â ALP, 5-Nº¸´Ù ºñƯÀÌÀûÀ̸ç occult alcohol use¸¦ º¸´Âµ¥ »ç¿ëÇϱ⵵

ÇÑ´Ù.

ALP isoenzyme : liver, bone, placenta, small intestine

60¼¼ À̻󿡼­ Á¤»óÀûÀ¸·Î ALP°¡ ¾à°£ »ó½ÂÇÒ¼ö ÀÖÀ¸¸ç

bone turnover°¡ ºü¸¥ û¼Ò³â¿¡¼­µµ Áõ°¡µÉ¼ö ÀÖ´Ù.

Liver-derived ALP»ó½ÂÀº cholestasis¿¡ ƯÀÌÀûÀÌÁö´Â ¾ÊÀ¸¸ç, 3¹è¹Ì¸¸À϶§´Â ¸ðµç ÇüÅÂÀÇ

°£Áúȯ¿¡¼­ º¼¼ö ÀÖ´Ù. 4¹è ÀÌ»ó »ó½ÂÇÒ¶§´Â

i) cholestatic liver disorder

ii) infiltrative liver disease(cancer)

iii) rapid bone turnover(Paget's disease)¿¡¼­ ÁÖ·Î º¼¼ö ÀÖ´Ù.

heat-stable fraction = placenta fraction

5-N, GGT : liver diseaseÀ̿ܿ¡¼± µå¹°´Ù.

2. Biosynthetic functionÀ» ÃøÁ¤ÇÏ´Â °Ë»ç

1) serum albumin

°£¿¡¼­ ÇÕ¼ºµÇ¸ç ¹Ý°¨±â´Â 15-20ÀÏÀÌ´Ù.

µû¶ó¼­ acute or mild hepatic dysfunction¶§´Â ÁÁÀº indicator°¡ µÇÁö ¸øÇÑ´Ù.

3.0 g/dL ¹Ì¸¸ÀÏ ¶§´Â chronic liver disease°¡´É¼ºÀÌ Áõ°¡ÇÑ´Ù.

±×·¯³ª hypoalbuminemia´Â °£Áúȯ¿¡ ƯÀÌÀûÀÌÁö´Â ¾Ê´Ù.

: protein malnutrition, protein-losing enteropathy, N.S,

chronic infection(IL-1, TNF levelÀÌ Áõ°¡µÇ´Â)

2) serum globulin

¥ã-globulin : CLD(chronic hepatitis, liver cirrhosis)¿¡¼­ Áõ°¡

LC¿¡¼­ ¥ã-globulinÁõ°¡´Â AbÇÕ¼ºÀÌ Áõ°¡Çϱ⠶§¹®À̸ç, ÀÌ·¯ÇÑ Ç×üÀÇ ÀϺδ intestinal

bascteria¿¡ ÀÇÇØ »ý¼ºµÈ °ÍÀÌ´Ù. hepatic circulationÀ» ºñÄÑ Áö³ª°¡¹Ç·Î bacterial AgÀ»

Á¦°ÅÇÏÁö ¸øÇϱ⠶§¹®¿¡ Ç×ü ÇÕ¼ºÀÌ Áõ°¡ÇÑ´Ù.

IgG¡è : autoimmune hepatitis

IgM¡è : primary biliary cirrhosis

IgA¡è : alcoholic liver disease

3) coagulation factors

factor VIIIÀ» Á¦¿ÜÇϰí´Â ¸ðµÎ °£¼¼Æ÷¿¡¼­ ÇÕ¼ºµÇ´Âµ¥ ¹Ý°¨±â°¡ ª¾Æ¼­ hepatic synthetic

fxÀ» ÃøÁ¤ÇÏ´Â ´ÜÀÏÀÇ °¡Àå ÁÁÀº °Ë»ç¹ýÀ̸ç aucte parenchymal liver diseaaseÀÇ

¿¹Èĸ¦ Æò°¡Çϴµ¥ µµ¿òÀÌ µÈ´Ù.

* PT prolongation(5ÃÊÀÌ»ó), vit K·Î ±³Á¤X => poor Px sign

3. Liver biopsy Indication

¨ç hepatocellular disease

¨è prolonged hepatitis

¨é unexplained hepatomegaly

¨ê unexplained splenomegaly

¨ë hepatic filling defect

¨ì FUO

¨í malignant lymphoma staging