Serum Glutamate Dehydrogenase Is Not a Reliable Marker of Liver Cell Necrosis in Alcoholics

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Serum Glutamate Dehydrogenase Is Not a Reliable Marker of Liver Cell Necrosis in Alcoholics J Clin Pathol: first published as 10.1136/jcp.35.2.207 on 1 February 1982. Downloaded from J Clin Pathol 1982;35;207-210 Serum glutamate dehydrogenase is not a reliable marker of liver cell necrosis in alcoholics WJ JENKINS, SB ROSALKI, Y FOO, PJ SCHEUER, E NEMESANSZKY,* S SHERLOCK From the Departments of Medicine, Chemical Pathology and Histopathology, Royal Free Hospital and School of Medicine, Pond Street, London NW3 2QG SUMMARY Serum glutamate dehydrogenase (EC 1.4.1.3.) activity was measured in 73 hospital patients who had a history of chronic alcohol abuse and who all had a liver biopsy performed. High levels of serum GDH activity occurred in those patients with recent excess alcohol con- sumption independently of the underlying liver histology, and did not discriminate between those patients with and those without alcoholic hepatitis. Since alcoholic hepatitis is thought to be a precursor of GDH reliably reflects liver cell necrosis, and that of cirrhosis, a convenient and reliable marker of liver a serum value two and a half times the normal value cell necrosis would be extremely useful in following is indicative of alcoholic hepatitis.8 For these reasons the progress of liver disease in alcoholic patients. it was suggested that the serum GDH activity should Repeated liver biopsiesare impractical for monitoring be estimated routinely in alcoholics. However, the copyright. purposes, and raised activities of the so-called possibility that recent alcohol consumption might hepatic enzymes commonly measured in serum are increase serum activities of GDH independent of found in all histological stages of alcoholic liver histological change was not investigated. GDH disease from steatosis to cirrhosis.' Conversely in activity is considerably raised in liver biopsies from alcoholic hepatitis the serum transaminase activities recently drinking patients with alcoholic steatosis,9 may be only moderately raised or even normal.2 and high activities of the enzyme in serum may at Furthermore, the transaminases are not specific to least partly reflect this increase in hepatic activity. http://jcp.bmj.com/ the liver, and raised serum activities may reflect We have studied the effect of recent heavy con- damage to other organs. Gamma-glutamyl trans- sumption of alcohol on the activity of GDH in both peptidase (EC 2.3.2.2.) (yGT) has been suggested as serum and liver in unselected alcoholic patients a useful marker of alcoholic liver disease,3 but the undergoing diagnostic liver biopsy, and tested the correlation between raised serum yGT activities and usefulness of serum GDH measurement in dis- liver cell necrosis is poor,4 and increases due to other criminating between those with and those without hepatic causes are common. alcoholic hepatitis. The level of glutamate dehydrogenase (GDH) in on September 23, 2021 by guest. Protected serum might be expected to provide a more reliable Patients and methods index of liver damage in alcoholics, since its activity in the liver is very much higher than in other organs.5 PATIENTS Also, it is concentrated in the centrilobular zones of Seventy-three inpatients (56 men, 17 women) were the liver, where alcohol exerts its greatest toxic studied. They all had a history of alcohol abuse, and effects,6 and within the hepatocytes it is found all had either symptoms, physical signs, or bio- exclusively in mitochondria, which are thought to be chemical evidence of liver disease. Other possible damaged early in the course of alcoholic liver causes of liver disease besides alcohol were excluded disease.7 In a study of 100 alcoholic patients, by the relevant investigations. The reasons for Van Waes and Lieber claimed that the serum activity admission to hospital varied. Some patients were admitted for diagnostic liver biopsy, some for Accepted for publication 3 July 1981 detoxification, and some had the clinical syndrome *Present address: Postgraduate Medical School, Ist Depart- of overt alcoholic hepatitis. All had a percutaneous ment of Medicine, 1135 Budapest, Hungary. liver biopsy performed. Venous blood was sampled 207 J Clin Pathol: first published as 10.1136/jcp.35.2.207 on 1 February 1982. Downloaded from 208 Jenkins, Rosalki, Foo, Scheuer, Nemesanszky, Sherlock for serum enzyme analysis thirty minutes before the with, or without fat or cirrhosis; and eight had biopsy. cirrhosis without evidence of alcoholic hepatitis. A detailed history of alcohol drinking was taken from each patient. The patients were divided arbi- ENZYME ASSAYS trarily into those who had consumed > 80 g of Aspartate aminotransferase (AST), GDH and yGT ethanol/day immediately before liver biopsy, were assayed in serum by standard laboratory designated the "recent alcohol excess" group, and techniques.10-12 Serum AST was determined immedi- those who had consumed <80 g of ethanol/day in ately, and the samples of serum were stored at the preceding week, designated the "no recent - 20°C before GDH and yGT were assayed. Most alcohol excess" group. In practice many of the samples were examined within two weeks of col- patients admitted specifically for liver biopsy had lection, and all within two months. Stability studies considerably reduced their alcohol intake before confirmed that the activities of these enzymes were admission, and others, particularly those with unaltered during storage for this period. alcoholic hepatitis, had been in hospital without In 49 patients the amount of liver tissue obtained alcohol for more than a week before liver biopsy by biopsy exceeded that judged necessary for was performed. histological assessment. The remaining portions of Twelve non-alcoholic patients admitted for liver these biopsies were disrupted in 0-25 mol/l sucrose biopsy for suspected liver disease, but who had containing 3 mmol/l imidazole, pH 7-4, at 4°C in normal serum liver function tests at the time, and a glass Dounce homogeniser. GDH activity and whose liver biopsies were subsequently found to be protein content were assayed in the resulting normal, were used as controls in the study of GDH homogenates. activities in the liver. The results were analysed statistically by the Wilcoxon rank sum test. HISTOLOGY Histology of the liver biopsies was interpreted Results independently without knowledge of the serum copyright. enzyme analyses. Sections were stained by standard Most of our alcoholic patients had raised activities methods and examined for the presence of fat, of one or more of the serum enzymes assayed: inflammation, fibrosis, necrosis and Mallory bodies. 58 had raised serum AST; 59 had raised yGT; and Eight patients had histologically normal livers; 37 had raised GDH. Fig. 1 shows the individual 38 had alcoholic steatosis; 19 had alcoholic hepatitis values in patients with and without recent excessive http://jcp.bmj.com/ 4, Glutamate V Glutamate Aspartate dehydrogenase transpeptidase aminotransferase , 40 E 1 1I 0 a a30 0 lI -aE Wo 0, c 20 0 a 0 on September 23, 2021 by guest. Protected x ._ 0 a E10.- 0 000. 4.. :.0 0 e -> _ 42 St 0 *0 Q. 45 0 a : . : S0*. 3 *^J .% %0- 0@ 2 000o0 0. E 0 000 0 4 1 CA* IS i i - N i CiN 1 %k c 0 w 0 .- I I &' <. N.'z *\' ,X\. 0ro&N' Fig. 1 Serum GDH, yGT and AST in alcoholic patients grouped by liver biopsy histology. (0 > 80 g ethanol/day before biopsy; 0 < 80 g ethanol/day before biopsy) J Clin Pathol: first published as 10.1136/jcp.35.2.207 on 1 February 1982. Downloaded from .Serum glutamate dehydrogenase is not a reliable marker of liver cell necrosis in alcoholics 209 consumption of alcohol grouped according to the criminating between those with and those without histological diagnosis. Clearly the individual values alcoholic hepatitis. However, the serum GDH of serum enzyme activities show a considerable activity in those patients who were drinking heavily overlap among the various histological groups, and immediately before liver biopsy is significantly serum GDH is no better than AST or yGT in dis- higher (p < 0-01) than in those who were not, irrespective of the underlying histological diagnosis .121 (Fig. 2). p<O-O1 Fig. 3 shows the specific activities of GDH in 0 49 liver biopsies from alcoholic patients, and in the 10. 12 control patients. The activities of GDH in the livers of those alcoholic patients, who had a history 0 of recent alcohol excess and whose liver biopsies 81 showed fatty change only, are significantly higher (p < 0-01) than in the normal controls. In contrast the hepatic activities of GDH are lower (p < 0 01) 0 in those patients with alcoholic hepatitis presumably Enzyme activity bl expressed as multiple 0 because of liver cell necrosis. 0@ upper limit of normal 0 90 Discussion 4. 0S 0 Our results clearly contrast with those of a similar previous study of alcoholics, in which the activity of 2 GDH in plasma was reported to be a reliable marker *% of liver cell injury.8 We found that the serum GDH activity was considerably raised in many of our 0 Recent alcohol No recent alcohol alcoholic patients whose liver biopsies showed fatty copyright. excess excess change alone, whereas other patients with histo- severe alcoholic Fig. 2 Serum GIDH in alcoholic patients (0 > 80 g logically proven and often hepatitis ethanol/day before liver biopsy; 0 < 80 g ethanol/day had only slightly raised serum GDH activities. Thus, before biopsy) a serum GDH activity two and a half times the normal value does not discriminate between those alcoholic patients who had alcoholic hepatitis, and others who had not, as was previously claimed. However, we have shown that recent heavy http://jcp.bmj.com/ alcohol consumption increases the activity of GDH .c 2500 in both serum and liver. This is compatible with 0 induction of the enzyme by alcohol, and limits the use of serum GDH measurement as an indicator of 8 2000 pathological change.
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