1. Clinical Biochemistry For GPs
Dr Anne-Marie Kelly / Dr Graham Horsman
Consultant Chemical Pathologists
Wythenshawe Hospital

2. Outline of talk
Telephone conversations to illustrate clinical biochemistry problems around LFTs
Alkaline phosphatase
Alanine aminotransferase
Bilirubin
Suggested algorithms for investigation of abnormal LFTs
How are abnormal results reported out of hours?
Profile requesting in Sunquest ICE

3. Case1 62y male, epigastric pain Total Protein 82 g/L Albumin 43 g/L
Bilirubin 12 umol/L
Alk Phos 145 U/L
ALT 35 U/L

4. Isolated elevated Alkaline Phosphatase
Physiological causes:
Child / adolescent (3-4 x)
Over 70s (1.5x)
Late pregnancy (3x)
Liver origin?
GGT

5. Isolated elevated Alkaline Phosphatase
GGT
Normal
NON-HEPATIC
Vitamin D deficiency
Malignancy – Ca prostate
Paget’s
Elevated
Ultrasound Liver
ABNORMAL
Biliary dilatation
Space occupying lesion
NORMAL
Drugs – phenytoin
Alcohol
Primary Biliary Cirrhosis

6. Case 2 54y male, tired Total protein 70 g/L Albumin 44 g/L
Bilirubin 12 umol/L
AlkPhos 61 U/L
ALT 68 U/l
( ALT 79 U/L 6 months previously)

7. Isolated Elevated ALT ( >3-5x or >6m)
Step1
Drugs/ supplements
Alchohol – GGT >2x, AST:ALT ratio >2:1
Hepatitis B / C – viral serology
Haemochromatosis – iron satn >50%
Non-alcoholic steatohepatosis – incl DM, obesity - ultrasound

8. Isolated Elevated ALT ( >3-5x or >6m)
Step 2
Autoimmune hepatitis – autoantibodies
Wilson’s disease – Copper / caeruloplasmin
Alpha-1 –antitrypsin deficiency – A1AT
Step 3
Observation - <2x increase
Liver biopsy?

9. Case 3 40 y male “well male check-up”, impotence Total protein 68 g/L
Albumin 46 g/L
Bilirubin 38 umol/L
Alk Phos 63 U/L
ALT 17 U/L
GGT 13 U/L

10. Isolated hyperbilirubinaemia
High Bilirubin
Unconjugated
Exclude haemolysis
No Haemolysis
GILBERT’s
Drugs- rifampicin
Haemolysis
e.g. hereditary
spherocytosis
Conjugated
Drugs –steroids
Rare inherited disorders

11. What happens to abnormal results out of hours?
Critical results are checked
GotoDoc are telephoned
The abnormal results, together with the request form and a cover sheet are faxed to GotoDoc
Policy based on RCPath guidelines
If problems, on-call Consultant contacted by lab for advice

12. Critical Biochemistry Blood Results:
Sodium <12o or >150 mmol/L
Potassium <2.8 or >6.0 mmol/L
Creatinine >400 umol/L (not known)
Calcium <1.8 or >3.5 mmol/L
CRP >300 mg/L
ALT >700 U/L
TroponinI >100 ng/L
Glucose >20 mmol/L (non-diabetic)
>25 mmol/L (known diabetic)