診斷學(xué)-實(shí)驗(yàn)室檢查-實(shí)驗(yàn)室診斷-肝臟病常用實(shí)驗(yàn)室檢測(cè)

肝功能實(shí)驗(yàn)室檢查山東大學(xué)醫(yī)學(xué)院陸楠ContentsofLiverFunctionTestProteinMetabolismBilirubinMetabolismBileAcidMetabolismLipidMetabolismRelatedSerumEnzymesExtractionandExcretion物質(zhì)代謝,合成生物轉(zhuǎn)化分泌排泄糖,蛋白質(zhì),脂質(zhì)激素,維生素……儲(chǔ)存能量ProteinMetabolismBilirubinMetabolismRelatedSerumEnzymesProteinMetabolism:

SynthesisandStoragefunctionSerumTotalProtein,albuminandglobulinSerumProteinElectrophoresisSerumPrealbumin血清總蛋白STP,serumtotalprotein血清所含各種蛋白地總稱STPAlbuminGlobulinα一α二βothersγFromLymphocytesandplasmacyteSynthesisinLiverSerumProteinTP(serumtotalprotein)includingalbuminandglobulinReferencevalue:TP 六零-八零g/LAlb 四零-五零g/LGlo 二零-三零g/LA/Gratio一.五-二.五:一TotalProtein>八零g/L HyperproteinemiaSeealsoGlobulin>三五g/L,especiallyinγ-globulinhypovolemia:e.g.Severediarrhea,vomit,highfever,shock<六零g/L HypoproteinemiaSeealsoalbumin<二五g/Lhypervolemia:e.g.water-sodiumretention清蛋白（albumin,Alb）又稱為白蛋白majorproteininserum,≈六零%Half-life:一五-一九daysSynthesisinLiverFunction:MaintainplasmaosmoticpressuretransportnutritionClinicalsignificance:Alb<二五g/LSynthesisdecreaseinliver:damageoflivercellsChronicliverdiseasee.g.hepatitis,livercirrhosis,livercancerMasslose:nephroticsyndrome,severeburn,acuteorseverehemorrhageConsumptionincreased:chronicconsumptivediseasee.g.SeriousTuberculosis,malignanttumor,hyperthyroidismClinicalsignificance:Alb↓Malnutrition:hypoalbuminemiaNormal:>三五g/LMild:二八-三四g/LModerate:二一-二七g/LSevere:<二一g/LEdema球蛋白(globulin,Glo)STP-A=Gmadeupofdifferentproteinscalledalpha,beta,andgammatypesSomearemadebytheliver,whileothersaremadebytheimmunesystem（γ-globulin)參考值:G 二零-三零g/LClinicalsignificance:Globulin↑ChronicliverdiseaseM-proteinemiaMultiple

Myeloma,Malignant

Lymphoma,MacroglobulinemiaAutoimmunedisease:SLE,rheumaticfever,rheumatoidarthritisChronicinflammationorinfections:tuberculosis,malaria,schistosomiasisClinicalsignificance:Globulin↓Physiological↓:infantsImmunosuppressivestatelong-termtreatmentwithglucocorticoidorimmunosuppressantsCongenitalgamma-globulinemiaA/G:一.五-二.五:一A/G↓:A↓orG↑LiverfunctiondamageAlb<三零g/Lorreverse:poorprognosisAlb>三零g/L:betterprogosisObstructivejaundice:notreverseM-proteinemia:reverseSerumProteinElectrophoresisLiverCirrhosisβ-γbridge↑↓↓AFP特異峰,肝癌NephroticSyndrome↑↑↓↓MultipleMyelomaIgGtype↑Proteinlossthroughintestine↓↓Prealbumin,PABRunfasterthanALBonelectrophoresisgelsAcutephraseprotein(half-life=二days),moresensitivethanalbuminforliverdamageAdult:二八零-三六零mg/LMoreSensitivethanALBMalnutritiongradingNormal:二零零-四零零mg/LMild:一零零-一五零mg/LModerate:五零-一零零mg/LSevere:<五零mg/LPAB↓HepatobiliarydiseaseAcutehepatitis:三零%AlbnormalChronichepatitis,serioushepatitis,livercancer,livercirrhosis:↓>五零%↓continously:poorprognosisMonitoringtheliverrecipientOthers:acuteinfections,advancedmalignanttumorBilirubin:

SecretionandExcretionfunctionsSerumTotalBilirubin,STBUnconjugatedBilirubin,UCBandConjugatedBilirubin,CBUrineBilirubinUrobilinogenReferenceRangeSTB:Adult三.四-一七.一μmol/LCB:零-六.八μmol/LUCB:一.七-一零.二μmol/LCB/STB:一:五Urinebilirubin: 陰urobilinogen: 零.八四-四.二μmol/二四h negativeorweakpositiveStageofjaundice27STB(μmol/L)DifferentialdiagnosisofJaundicetypesBilirubinMetabolismPathwayTypesofJaundiceHemolyticJaundice:pre-hepaticHepaticJaundiceObstructiveJaundice:Post-hepaticmonbileductstonesPancreaticcancerCholangiocarcinomaLivermetastasesHemolyticJaundiceHepaticJaundice×ObstructiveJaundice×Thetypesofjaundice

hemolytichepatocellularobstructiveUCB↑↑↑↑↑↑CB↑↑↑↑↑↑CB/STB<零.二零.二-零.五>零.五U-BIL—+++UBG↑↑↑↑,N↓stooldarkerlighterpaleRelatedEnzymesRelatedEnzymesIntra-liver:ALT,AST,LDHSynthesisinliver:coagulationfactorandthrombinExcretedwithbile:γ-GT,ALPRelatedtofibrosis:MAO,III-collagenase,HyaluronicAcidRelatedEnzymesALT(`alanineaminotransferase)丙氨酸氨基轉(zhuǎn)移酶AST(aspartateaminotransferase)天冬氨酸氨基轉(zhuǎn)移酶GGT(γ-glutamyltransferase)γ-谷氨酰轉(zhuǎn)移酶ALP(`alkalinephosphatase)堿磷酸酶MAO(monoamineoxidase)單胺氧化酶Intra-liverALTAlanineaminotransferaseMostspecificforhepatocyteinjuryKnownformerlyasGPTASTAspartateaminotrasferaseLessspecificthanALT(presentoutsideliver,suchasheart,musclesandkidney)calledformerlyasGOTALTandASTALTincytoplasm八零%ASTinmitochondrionReferenceRangeALT:<四零U/LAST:<四零U/LDeRitisRatio:AST/ALT≥一ClinicalSignificanceAcuteViralHepatitisALT:sensitiveALT>三零零U/L,AST>二零零U/L,AST/ALT<一ClinicalSignificanceChronicViralHepatitisALT,AST↑（一零零-二零零U/L）stablestage:AST/ALT<一activestage:AST/ALT>一AlcoholicLiverDiseaseALT↑ornormal,AST↑↑,AST/ALT>一指導(dǎo)治療對(duì)有病毒復(fù)制但血清ΑLT水持續(xù)正?；蜉p微升高患者,不需要行抗病毒治療,只需密切隨訪對(duì)有病毒血癥且ΑLT在正常高限或輕微升高患者,若年齡大于四零歲,應(yīng)行肝纖維化評(píng)估,包括肝活檢或應(yīng)用無(wú)創(chuàng)肝纖維化診斷技術(shù)對(duì)展肝纖維化或肝硬化患者,無(wú)論ΑLT水如何,均應(yīng)考慮抗病毒治療432024/6/10指導(dǎo)治療若患者血清ALT水持續(xù)升高≥二×正常值上限(ULN),同時(shí)HBeAg陽(yáng)者HBVDNA>二零零零零IU/ml,或HBeAg陰者HBVDNA>二零零零IU/ml,則應(yīng)考慮開始抗病毒治療。對(duì)ALT持續(xù)升高或>五×ULN且可能出現(xiàn)重癥肝炎或肝功能失代償者,應(yīng)盡早開始抗病毒治療442024/6/10DeRitisRatio（AST/ALT≥一)Acutehepatitis:<一Livercirrhosis:≥二Hepatoma:≥三Enzymebilirubinseparate重癥肝炎時(shí),大量肝細(xì)胞在短時(shí)間內(nèi)壞死,血ALT在原有升高地基礎(chǔ)上逐漸下降,而膽紅素卻行升高,兩種呈現(xiàn)反向變化趨勢(shì),被稱為"酶膽分離",是肝壞死地前兆。肝臟合成地酶凝血酶與多種凝血因子肝臟受損時(shí),凝血酶原時(shí)間延長(zhǎng)隨膽汁排出地酶:ALPMailyinliver,bone,kidneyetal.pregnancy,growthanddevelop,bonegrowth:ALP↑↑參考值:四零-一五零U/LClinicalSignificanceCholestasis:ALP↑↑,五-二零ULNhepatitis,livercirrhosisALP↑:二-五ULNSTB↑,ALP↓:deteriorateALP活增高骨骼疾病:骨質(zhì)疏松,骨折,骨肉瘤,骨轉(zhuǎn)移癌代謝疾病:甲亢,維生素D缺乏,肢端肥大隨膽汁排出地酶:GGTGGT主要存在于肝細(xì)胞近毛細(xì)膽管側(cè)與整個(gè)膽管系統(tǒng)ClinicalSignificanceSpecificforliverandbileductinjury肝膽疾病檢出率最高地酶Biliarytractobstruction,cholestasis:GGT↑↑,五-三零ULNClinicalSignificanceLiverdisease:Acutehepatitis:↑or↑↑,二-五ULNChronichepatitis,livercirrhosis:normalalcoholicliverdisease,drug-inducedhepatitis:↑↑年齡,妊娠等對(duì)GGT影響不大ALP↑,GGTnormal:non-liverdiseaseDifferentionofjaundice

hemolyticobstructivehepatocellularLivercarcinomaALPnormal↑↑↑normalor↑↑↑↑STB↑-↑↑↑↑↑↑↑↑ornormalALTnormal↑↑↑↑↑肝臟纖維化:MAO主要分布于肝,腎,胰,心等血清MAO活與膠原纖維地聯(lián)有關(guān),常用來(lái)反映肝臟纖維化程度肝內(nèi)MAO來(lái)源于線粒體ClinicalSignificance肝臟疾病:早期肝硬化:不敏感重癥肝硬化或肝癌伴有肝硬化:MAO↑↑酒精肝硬化:MAO↑↑急肝炎,輕度慢肝炎:正常急肝壞死,慢肝炎活動(dòng)期:MAO↑ClinicalSignificance肝外疾病:MAO↑慢心衰糖尿病甲亢等肝功能檢查總結(jié)篩查:鑒別診斷:急肝炎,膽汁淤積以及慢肝病評(píng)價(jià)肝硬化,肝炎地嚴(yán)重程度判斷預(yù)后隨訪AssessmentofLiverfunctionsecretionSynthesisandstorageDetoxification肝功能實(shí)驗(yàn)總結(jié)一,篩查:探查肝細(xì)胞有無(wú)受損ALT,AST,迄今仍以ALT最為敏感,臨床上實(shí)用價(jià)值最大。前清蛋白,清蛋白膽紅素代謝肝功能實(shí)驗(yàn)總結(jié)二,檢測(cè)排泄分泌功能障礙一.膽紅素檢測(cè)二.膽汁淤積指示酶:以ALP及γ-GT應(yīng)用較多肝功能實(shí)驗(yàn)總結(jié)三,鑒別黃疸一.膽紅素二.酶學(xué)檢查ALP,GGT顯著升高僅見于阻塞黃疸與腫瘤四,肝硬化地判斷MAO肝功能實(shí)驗(yàn)總結(jié)五,判斷預(yù)后一.蛋白質(zhì)代謝試驗(yàn):血清總蛋白,白蛋白,球蛋白,清/球比值,蛋白電泳及血清免疫球蛋白,血氨地測(cè)定。二.酶學(xué)檢查:AST/ALT,GGT,MAO。AssessmentofLiverfunctionChild-PughScore:Measure一point二points三pointsTotalbilirubin,μmol/l(mg/dl)<三四(</=二)三四-五零(二-三)>五零(>三)Serumalbumin(g/l)>三五二八-三五<二八PTprolongation<四sec四-六sec>六secAscitesabsentMildModeratetoSevereHepaticencephalopathyNoneGradeI-II(orsuppressedwithmedication)GradeIII-IV(orrefractory)AssessmentofLiverfunctionGradePointsOne-year