Liver blood test panel

Enter one set of liver blood tests. Each score appears as soon as the values it needs are filled in: the pattern of injury, fibrosis scores, and liver function and prognostic scores. Leave out anything you do not have.

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The scores

• R factor = (ALT ÷ ULN) ÷ (ALP ÷ ULN): 5 or more hepatocellular, 2 or less cholestatic, mixed in between. The new R uses the higher of ALT or AST. See the R factor page.
• Hy's law: ALT or AST above 3 times and bilirubin above 2 times the upper limit, with ALP below 2 times the upper limit.
• FIB-4 = (age × AST) ÷ (platelets × √ALT). Advanced fibrosis unlikely below 1.30 (2.0 from age 65), likely above 2.67.
• APRI = (AST ÷ ULN) ÷ platelets × 100. Significant fibrosis unlikely below 0.5; cirrhosis possible above 1.0 and likely above 2.0.
• AST to ALT ratio: above 1 suggests cirrhosis in chronic liver disease; 2 or more suggests alcohol-related liver disease.
• ALBI = (log₁₀ bilirubin × 0.66) − (albumin × 0.0852): grade 1 −2.60 or less, grade 2 up to −1.39, grade 3 above.
• MELD and MELD-Na as used for the MELD-Na page.
• MELD 3.0 = 1.33 × female + 4.56 × ln bilirubin + 0.82 × (137 − Na) − 0.24 × (137 − Na) × ln bilirubin + 9.09 × ln INR + 11.14 × ln creatinine + 1.85 × (3.5 − albumin) − 1.83 × (3.5 − albumin) × ln creatinine + 6. Bilirubin and creatinine in mg/dL, albumin in g/dL; bilirubin, INR and creatinine at least 1.0, creatinine at most 3.0, sodium 125 to 137, albumin 1.5 to 3.5.
• Child-Pugh as on the Child-Pugh page.
• Maddrey discriminant function = 4.6 × (prothrombin time − control) + bilirubin in mg/dL. 32 or more is severe alcohol-related hepatitis.

Cautions

• FIB-4 and APRI were validated in chronic liver disease. They overestimate fibrosis during acute hepatitis, when transaminases are markedly raised.
• MELD and Child-Pugh apply to cirrhosis. The Maddrey discriminant function applies only to alcohol-related hepatitis.
• Warfarin raises the INR and invalidates MELD, Child-Pugh and the Maddrey score.
• ALP from bone, pregnancy or growth raises it without liver disease. A raised GGT supports a liver source.

References

Kim WR, Mannalithara A, Heimbach JK, et al. MELD 3.0: the Model for End-Stage Liver Disease updated for the modern era. Gastroenterology. 2021;161(6):1887-1895.

Chalasani NP, Maddur H, Russo MW, et al. ACG Clinical Guideline: diagnosis and management of idiosyncratic drug-induced liver injury. Am J Gastroenterol. 2021;116(5):878-898.

Sterling RK, Lissen E, Clumeck N, et al. Development of a simple noninvasive index to predict significant fibrosis in patients with HIV/HCV coinfection. Hepatology. 2006;43(6):1317-1325.

Wai CT, Greenson JK, Fontana RJ, et al. A simple noninvasive index can predict both significant fibrosis and cirrhosis in patients with chronic hepatitis C. Hepatology. 2003;38(2):518-526.

Johnson PJ, Berhane S, Kagebayashi C, et al. Assessment of liver function in patients with hepatocellular carcinoma: a new evidence-based approach — the ALBI grade. J Clin Oncol. 2015;33(6):550-558.

Maddrey WC, Boitnott JK, Bedine MS, et al. Corticosteroid therapy of alcoholic hepatitis. Gastroenterology. 1978;75(2):193-199.