Cirrhosis laboratory findings
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2]
Overview
A range of laboratory values need to be obtained in the evaluation of cirrhosis, both to determine the severity of the disease, and to determine the causative factor. Liver function tests, complete blood count, basic metabolic panel and coagulation factors are standard in the evaluation of cirrhosis. More specific testing for markers and serum enzymes can be done when certain genetic causes and etiologies are suspected.
Laboratory Findings
- Laboratory abnormalities may be the first indication of cirrhosis.
- Common abnormalities include:
- Increased serum bilirubin levels
- Abnormal aminotransferase levels
- Elevated alkaline phosphatase
- Elevated gamma-glutamyl transpeptidase
- Prolonged prothrombin time
- Elevated international normalized ratio (INR)
- Hyponatremia
- Thrombocytopenia
Liver function tests:
- Aminotransferases :
- Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are usually moderately elevated
- AST is more often elevated than ALT
- LFTs may be normal in cirrhosis patients
- Alkaline phosphatase:
- Alkaline phosphatase is usually elevated
- High levels may be seen in patients with underlying cholestatic liver disease such as:
- Primary sclerosing cholangitis
- Primary biliary cirrhosis
- Gamma-glutamyl transpeptidase:
- Non specific
- Correlates with ALP levels
- Higher in CLD due to alcohol use:
- Mechanism of raised GGT in Alcoholic liver disease:
- Alcohol causes GGT release from hepatocytes
- Alcohol induces microsomal GGT in liver
- Bilirubin:
- Bilirubin levels may be normal or raised
- Albumin:
- Albumin levels reflect synthetic function of the liver
- Serum albumin levels helps grade the severity of cirrhosis
- Hypoalbuminemia is non specific for liver disease and may be seen in:
- Heart failure
- Nephrotic syndrome
- Protein-losing enteropathy
- Malnutrition.
- Prothrombin time:
- Prothrombin time reflects the degree of hepatic synthetic function.
- Worsening coagulopathy correlates with the severity of hepatic dysfunction.
- Serum chemistries :
Hyponatremia is common in patients with cirrhosis and ascites and is related to an inability to excrete free water. Due to ADH elevation Reflects poor prognosis Progressive rise in serum creatinine: hepatorenal syndrome Hematologic abnormalities:
Thrombocytopenia: most common Mechanism of thrombocytopenia: caused by portal hypertension with congestive splenomegaly: sequesters circulating platelets decreased thrombopoietin levels Leukopenia/neutropenia: due to hypersplenism with splenic margination. Anemia Mechanism of anemia: Acute and chronic gastrointestinal blood loss Folate deficiency Direct toxicity due to alcohol Hypersplenism Bone marrow suppression ( hepatitis-associated aplastic anemia) Anemia of chronic disease (inflammation) Hemolysis Other abnormalities — Globulins tend to be increased Disseminated intravascular coagulation Fibrinolysis Vitamin K deficiency Dysfibrinogenemia Insulin resistance: nonalcoholic fatty liver disease Diabetes: seen in patients with hemochromatosis
Diagnosis of Cirrhosis
Laboratory findings —
Laboratory abnormalities may be the first indication of cirrhosis.
Common abnormalities include:[1][2]
- Increased serum bilirubin levels [3]
- Abnormal aminotransferase levels [4][5][6][7][8][9][10][11][12][13][14]
- Elevated alkaline phosphatase / gamma-glutamyl transpeptidase [5][15][16]
- Prolonged prothrombin time
- Elevated international normalized ratio (INR)
- Hyponatremia
- Thrombocytopenia
Liver function tests
- Aminotransferases :[17][18][19][20][21][22][23]
- Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are usually moderately elevated
- AST is more often elevated than ALT
- Levels may be normal
- Alkaline phosphatase: [24]
- Alkaline phosphatase is usually elevated
- High levels may be seen in patients with underlying cholestatic liver disease such as:
- Primary sclerosing cholangitis
- Primary biliary cirrhosis
- Higher in CLD due to alcohol use:
- Alcohol causes GGT release from hepatocytes
- Alcohol induces microsomal GGT in liver
- Bilirubin: Bilirubin levels may be normal or raised
- Albumin: Albumin levels reflect synthetic function of the liver
- Serum albumin levels helps grade the severity of cirrhosis
- Hypoalbuminemia is non specific for liver disease: heart failure, nephrotic syndrome, protein-losing enteropathy, or malnutrition.
- Prothrombin time – Prothrombin time reflects the degree of hepatic synthetic function. [27]
- Worsening coagulopathy correlates with the severity of hepatic dysfunction.
Serum chemistries :
- Hyponatremia is common in patients with cirrhosis and ascites and is related to an inability to excrete free water. [28]
- Due to ADH elevation
- Reflects poor prognosis
- Progressive rise in serum creatinine: hepatorenal syndrome
Hematologic abnormalities: [29]
- Thrombocytopenia: most common
- Mechanism of thrombocytopenia:
- caused by portal hypertension with congestive splenomegaly: sequesters circulating platelets
- decreased thrombopoietin levels
- Leukopenia/neutropenia: due to hypersplenism with splenic margination.
- Anemia
- Mechanism of anemia:
- Acute and chronic gastrointestinal blood loss
- Folate deficiency
- Direct toxicity due to alcohol
- Hypersplenism
- Bone marrow suppression ( hepatitis-associated aplastic anemia)
- Anemia of chronic disease (inflammation)
- Hemolysis
- Other abnormalities — Globulins tend to be increased [30]
- Disseminated intravascular coagulation
- Fibrinolysis
- Vitamin K deficiency
- Dysfibrinogenemia
- Insulin resistance: nonalcoholic fatty liver disease
- Diabetes: seen in patients with hemochromatosis [31][32]
The following findings are typical in cirrhosis:
- Aminotransferases - AST and ALT are moderately elevated, with AST > ALT, however, normal aminotransferases do not preclude cirrhosis.
- Alcoholic liver disease - AST and ALT are both elevated but less than 300 IU/L with a AST:ALT ratio > 2.0
- Alkaline phosphatase - It is elevated but usually less than two to three times the upper limit. Patients with primary biliary cirrhosis and primary sclerosing cholangitis may have higher levels.
- GGT -- correlates with AP levels. It is typically much higher in chronic liver disease from alcohol.
- Bilirubin - may elevate as cirrhosis progresses.
- Albumin - levels fall as the synthetic function of the liver declines with worsening cirrhosis since albumin is exclusively synthesized in the liver.
- Prothrombin time - increases since the liver synthesizes clotting factors.
- Globulins - increase due to shunting of bacterial antigens away from the liver to lymphoid tissue which induces immunoglobulin production.
- Serum sodium- hyponatremia due to inability to excrete free water resulting from high levels of ADH and aldosterone.
- Thrombocytopenia - due to both congestive splenomegaly as well as decreased thrombopoietin from the liver, however this rarely results in a platelet count < 50,000/mL.
- Leukopenia and neutropenia - due to splenomegaly with splenic margination.
- Anemia - multifactorial in origin.
- Acute and chronic GI bleeding
- Folate deficiency
- Direct toxicity of alcohol
- Hypersplenism
- Bone marrow suppression
- Anemia of chronic disease
- Hemolysis
- Coagulation defects - the liver produces most of the coagulation factors and thus coagulopathy correlates with worsening liver disease.
- Ascitic fluid analysis - Most experts recommend a diagnostic paracentesis be performed if the ascites is new or if the patient with ascites is being admitted to the hospital. The fluid is then reviewed for its gross appearance, protein level, albumin, and cell counts (red and white). Additional tests will be performed if indicated such as Gram stain and cytology.[33]
- The Serum-ascites albumin gradient (SAAG) is probably a better discriminant than older measures (transudate versus exudate) for the causes of ascites.[34] A high gradient (> 1.1 g/dL) indicates the ascites is due to portal hypertension. A low gradient (< 1.1 g/dL) indicates ascites of non-portal hypertensive etiology. Ascites is broadly classified as two types based on the Serum-ascites albumin gradient (SAAG):
- Transudate - SAAG > 1.1 g/dL (indicates the ascites is due to portal hypertension).
- Exudate - SAAG < 1.1 g/dL (indicates the ascites is due to non-portal hypertension etiology).
- The Serum-ascites albumin gradient (SAAG) is probably a better discriminant than older measures (transudate versus exudate) for the causes of ascites.[34] A high gradient (> 1.1 g/dL) indicates the ascites is due to portal hypertension. A low gradient (< 1.1 g/dL) indicates ascites of non-portal hypertensive etiology. Ascites is broadly classified as two types based on the Serum-ascites albumin gradient (SAAG):
There is now a validated and patented combination of 6 of these markers as non-invasive biomarkers of fibrosis (and so of cirrhosis) : FibroTest.[35]
Other laboratory studies performed in newly diagnosed cirrhosis may include:
- Serology for hepatitis viruses.
- Autoantibodies
- ANA - present in autoimmune hepatitis
- Anti-smooth muscle antibody - present in autoimmune hepatitis
- Anti-mitochondrial antibody - present in primary biliary cirrhosis
- Anti-LKM
- Total iron, TIBC, transferrin saturation, and ferritin - elevated totat iron, reduced TIBC, elevated transferrin saturation, and elevated ferritin in hemochromatosis.
- Serum ceruloplasmin- low in Wilson's disease
- Immunoglobulin levels (IgG, IgM, IgA) - these are non-specific but may assist in distinguishing various causes.
- Chronic hepatitis B - Chronic hepatitis B can be diagnosed with detection of HBsAG > 6 months after initial infection. HBeAG and HBV DNA are determined to assess whether or not patients will need antiviral therapy.
- Serum protein electrophoresis - alpha-1 band absent in alpha-1 antitrypsin deficiency.
- Cholesterol and glucose
- Alpha 1-antitrypsin - reduced in alpha-1 antitrypsin deficiency.
Combinations of tests
Clinical prediction rules exist to help diagnosis cirrhosis according to a systematic review by the Rational Clinical Examination project.[2]
- Pohl's Index is if the AST/ALT ratio ≥1 and platelet count ≤ 150,000/mm3 then cirrhosis is very likely.[36]
- The Bonacini score is based on the ALT/AST ratio, platelet count, and INR.[37]
Another method is the Lok index[39]. Online calculators are available (link 1 and link 2).
In diagnosis of cirrhosis (Ishak scores, 5-6) in patients with hepatitis C, the aspartate aminotransferase to platelet ratio index (APRI) ratio > 1 suggests cirrhosis with accuracy of:[40]
- Sensitivity = 79%
- Specificity = 78%
A more recent meta-analysis has focused on the diagnosis of cirrhosis among patients with hepatitis C[41]. Using the Lok index:
- < 0.2 has hegative likelihood ratio of 0.21
- > 0.6 has positive likelihood ratio of 4.4
References
- ↑ Chalasani N, Younossi Z, Lavine JE, Diehl AM, Brunt EM, Cusi K, Charlton M, Sanyal AJ (2012). "The diagnosis and management of non-alcoholic fatty liver disease: practice guideline by the American Gastroenterological Association, American Association for the Study of Liver Diseases, and American College of Gastroenterology". Gastroenterology. 142 (7): 1592–609. doi:10.1053/j.gastro.2012.04.001. PMID 22656328.
- ↑ 2.0 2.1 Udell JA, Wang CS, Tinmouth J, FitzGerald JM, Ayas NT, Simel DL, Schulzer M, Mak E, Yoshida EM (2012). "Does this patient with liver disease have cirrhosis?". JAMA. 307 (8): 832–42. doi:10.1001/jama.2012.186. PMID 22357834.
- ↑ Krzeski P, Zych W, Kraszewska E, Milewski B, Butruk E, Habior A (1999). "Is serum bilirubin concentration the only valid prognostic marker in primary biliary cirrhosis?". Hepatology. 30 (4): 865–9. doi:10.1002/hep.510300415. PMID 10498635.
- ↑ Pratt DS, Kaplan MM (2000). "Evaluation of abnormal liver-enzyme results in asymptomatic patients". N. Engl. J. Med. 342 (17): 1266–71. doi:10.1056/NEJM200004273421707. PMID 10781624.
- ↑ 5.0 5.1 Kwo PY, Cohen SM, Lim JK (2017). "ACG Clinical Guideline: Evaluation of Abnormal Liver Chemistries". Am. J. Gastroenterol. 112 (1): 18–35. doi:10.1038/ajg.2016.517. PMID 27995906.
- ↑ Ruhl CE, Everhart JE (2010). "Trunk fat is associated with increased serum levels of alanine aminotransferase in the United States". Gastroenterology. 138 (4): 1346–56, 1356.e1–3. doi:10.1053/j.gastro.2009.12.053. PMC 2847039. PMID 20060831.
- ↑ Prati D, Taioli E, Zanella A, Della Torre E, Butelli S, Del Vecchio E, Vianello L, Zanuso F, Mozzi F, Milani S, Conte D, Colombo M, Sirchia G (2002). "Updated definitions of healthy ranges for serum alanine aminotransferase levels". Ann. Intern. Med. 137 (1): 1–10. PMID 12093239.
- ↑ Piton A, Poynard T, Imbert-Bismut F, Khalil L, Delattre J, Pelissier E, Sansonetti N, Opolon P (1998). "Factors associated with serum alanine transaminase activity in healthy subjects: consequences for the definition of normal values, for selection of blood donors, and for patients with chronic hepatitis C. MULTIVIRC Group". Hepatology. 27 (5): 1213–9. doi:10.1002/hep.510270505. PMID 9581673.
- ↑ Kaplan MM (2002). "Alanine aminotransferase levels: what's normal?". Ann. Intern. Med. 137 (1): 49–51. PMID 12093245.
- ↑ Nannipieri M, Gonzales C, Baldi S, Posadas R, Williams K, Haffner SM, Stern MP, Ferrannini E (2005). "Liver enzymes, the metabolic syndrome, and incident diabetes: the Mexico City diabetes study". Diabetes Care. 28 (7): 1757–62. PMID 15983331.
- ↑ Liangpunsakul S, Chalasani N (2012). "What should we recommend to our patients with NAFLD regarding alcohol use?". Am. J. Gastroenterol. 107 (7): 976–8. doi:10.1038/ajg.2012.20. PMC 3766378. PMID 22764020.
- ↑ Cohen JA, Kaplan MM (1979). "The SGOT/SGPT ratio--an indicator of alcoholic liver disease". Dig. Dis. Sci. 24 (11): 835–8. PMID 520102.
- ↑ Schuppan D, Afdhal NH (2008). "Liver cirrhosis". Lancet. 371 (9615): 838–51. doi:10.1016/S0140-6736(08)60383-9. PMC 2271178. PMID 18328931.
- ↑ "EASL Clinical Practice Guidelines: management of cholestatic liver diseases". J. Hepatol. 51 (2): 237–67. 2009. doi:10.1016/j.jhep.2009.04.009. PMID 19501929.
- ↑ Cabrera-Abreu JC, Green A (2002). "Gamma-glutamyltransferase: value of its measurement in paediatrics". Ann. Clin. Biochem. 39 (Pt 1): 22–5. doi:10.1258/0004563021901685. PMID 11853185.
- ↑ Moussavian SN, Becker RC, Piepmeyer JL, Mezey E, Bozian RC (1985). "Serum gamma-glutamyl transpeptidase and chronic alcoholism. Influence of alcohol ingestion and liver disease". Dig. Dis. Sci. 30 (3): 211–4. PMID 2857631.
- ↑ Sheth SG, Flamm SL, Gordon FD, Chopra S (1998). "AST/ALT ratio predicts cirrhosis in patients with chronic hepatitis C virus infection". Am. J. Gastroenterol. 93 (1): 44–8. doi:10.1111/j.1572-0241.1998.044_c.x. PMID 9448172.
- ↑ Williams AL, Hoofnagle JH (1988). "Ratio of serum aspartate to alanine aminotransferase in chronic hepatitis. Relationship to cirrhosis". Gastroenterology. 95 (3): 734–9. PMID 3135226.
- ↑ Wai CT, Greenson JK, Fontana RJ, Kalbfleisch JD, Marrero JA, Conjeevaram HS, Lok AS (2003). "A simple noninvasive index can predict both significant fibrosis and cirrhosis in patients with chronic hepatitis C". Hepatology. 38 (2): 518–26. doi:10.1053/jhep.2003.50346. PMID 12883497.
- ↑ Forns X, Ampurdanès S, Llovet JM, Aponte J, Quintó L, Martínez-Bauer E, Bruguera M, Sánchez-Tapias JM, Rodés J (2002). "Identification of chronic hepatitis C patients without hepatic fibrosis by a simple predictive model". Hepatology. 36 (4 Pt 1): 986–92. doi:10.1053/jhep.2002.36128. PMID 12297848.
- ↑ Vallet-Pichard A, Mallet V, Nalpas B, Verkarre V, Nalpas A, Dhalluin-Venier V, Fontaine H, Pol S (2007). "FIB-4: an inexpensive and accurate marker of fibrosis in HCV infection. comparison with liver biopsy and fibrotest". Hepatology. 46 (1): 32–6. doi:10.1002/hep.21669. PMID 17567829.
- ↑ Imbert-Bismut F, Ratziu V, Pieroni L, Charlotte F, Benhamou Y, Poynard T (2001). "Biochemical markers of liver fibrosis in patients with hepatitis C virus infection: a prospective study". Lancet. 357 (9262): 1069–75. doi:10.1016/S0140-6736(00)04258-6. PMID 11297957.
- ↑ Rosenberg WM, Voelker M, Thiel R, Becka M, Burt A, Schuppan D, Hubscher S, Roskams T, Pinzani M, Arthur MJ (2004). "Serum markers detect the presence of liver fibrosis: a cohort study". Gastroenterology. 127 (6): 1704–13. PMID 15578508.
- ↑ 24.0 24.1 Ellis G, Goldberg DM, Spooner RJ, Ward AM (1978). "Serum enzyme tests in diseases of the liver and biliary tree". Am. J. Clin. Pathol. 70 (2): 248–58. PMID 696683.
- ↑ Goldberg DM (1980). "Structural, functional, and clinical aspects of gamma-glutamyltransferase". CRC Crit Rev Clin Lab Sci. 12 (1): 1–58. PMID 6104563.
- ↑ Barouki R, Chobert MN, Finidori J, Aggerbeck M, Nalpas B, Hanoune J (1983). "Ethanol effects in a rat hepatoma cell line: induction of gamma-glutamyltransferase". Hepatology. 3 (3): 323–9. PMID 6132864.
- ↑ Chrostek L, Panasiuk A (2014). "Liver fibrosis markers in alcoholic liver disease". World J. Gastroenterol. 20 (25): 8018–23. doi:10.3748/wjg.v20.i25.8018. PMC 4081671. PMID 25009372.
- ↑ Papadakis MA, Fraser CL, Arieff AI (1990). "Hyponatraemia in patients with cirrhosis". Q. J. Med. 76 (279): 675–88. PMID 2217672.
- ↑ Qamar AA, Grace ND, Groszmann RJ, Garcia-Tsao G, Bosch J, Burroughs AK, Ripoll C, Maurer R, Planas R, Escorsell A, Garcia-Pagan JC, Patch D, Matloff DS, Makuch R, Rendon G (2009). "Incidence, prevalence, and clinical significance of abnormal hematologic indices in compensated cirrhosis". Clin. Gastroenterol. Hepatol. 7 (6): 689–95. doi:10.1016/j.cgh.2009.02.021. PMC 4545534. PMID 19281860.
- ↑ Triger DR, Wright R (1973). "Hyperglobulinaemia in liver disease". Lancet. 1 (7818): 1494–6. PMID 4123153.
- ↑ Bianchi G, Marchesini G, Zoli M, Bugianesi E, Fabbri A, Pisi E (1994). "Prognostic significance of diabetes in patients with cirrhosis". Hepatology. 20 (1 Pt 1): 119–25. PMID 8020880.
- ↑ Petrides AS, Vogt C, Schulze-Berge D, Matthews D, Strohmeyer G (1994). "Pathogenesis of glucose intolerance and diabetes mellitus in cirrhosis". Hepatology. 19 (3): 616–27. PMID 8119686.
- ↑ Warrell DA, Cox TN, Firth JD, Benz ED. Oxford textbook of medicine. Oxford: Oxford University Press, 2003. ISBN 0-19-262922-0.
- ↑ Runyon BA, Montano AA, Akriviadis EA, Antillon MR, Irving MA, McHutchison JG. The serum-ascites albumin gradient is superior to the exudate-transudate concept in the differential diagnosis of ascites. Ann Intern Med 1992;117:215-20. PMID 1616215.
- ↑ Halfon P, Munteanu M, Poynard T (2008). "FibroTest-ActiTest as a non-invasive marker of liver fibrosis". Gastroenterol Clin Biol. 32 (6): 22–39. doi:10.1016/S0399-8320(08)73991-5. PMID 18973844.
- ↑ Borroni G, Ceriani R, Cazzaniga M, Tommasini M, Roncalli M, Maltempo C; et al. (2006). "Comparison of simple tests for the non-invasive diagnosis of clinically silent cirrhosis in chronic hepatitis C." Aliment Pharmacol Ther. 24 (5): 797–804. doi:10.1111/j.1365-2036.2006.03034.x. PMID 16918883.
- ↑ Colli A, Colucci A, Paggi S, Fraquelli M, Massironi S, Andreoletti M; et al. (2005). "Accuracy of a predictive model for severe hepatic fibrosis or cirrhosis in chronic hepatitis C.". World J Gastroenterol. 11 (46): 7318–22. PMID 16437635.
- ↑ 38.0 38.1 Does this patient have cirrhosis? JAMA 2012
- ↑ Lok AS, Ghany MG, Goodman ZD, Wright EC, Everson GT, Sterling RK; et al. (2005). "Predicting cirrhosis in patients with hepatitis C based on standard laboratory tests: results of the HALT-C cohort". Hepatology. 42 (2): 282–92. doi:10.1002/hep.20772. PMID 15986415.
- ↑ Gara N, Zhao X, Kleiner DE, Liang TJ, Hoofnagle JH, Ghany MG (2013). "Discordance among transient elastography, aspartate aminotransferase to platelet ratio index, and histologic assessments of liver fibrosis in patients with chronic hepatitis C." Clin Gastroenterol Hepatol. 11 (3): 303–308.e1. doi:10.1016/j.cgh.2012.10.044. PMID 23142332.
- ↑ Chou R, Wasson N (2013). "Blood tests to diagnose fibrosis or cirrhosis in patients with chronic hepatitis C virus infection: a systematic review". Ann Intern Med. 158 (11): 807–20. doi:10.7326/0003-4819-158-11-201306040-00005. PMID 23732714.