Lab Tests

Glucose
Also known as: Blood sugar; Fasting blood sugar; FBS; Fasting blood glucose; FBG;
Fasting plasma glucose; FPG; Blood glucose; Oral Glucose Tolerance Test; OGTT; GTT;
Urine glucose
Formal name: Blood Glucose; Urine Glucose
Related tests: Urinalysis; Insulin; C-Peptide; A1c; Microalbumin
Why Get Tested?
To determine if your blood glucose level is within healthy ranges; to screen for, diagnose,
and monitor hyperglycemia, hypoglycemia, diabetes, and pre-diabetes
When to Get Tested?
Blood glucose: as part of a regular physical, when you have symptoms suggesting
hyperglycemia or hypoglycemia, and during pregnancy; if you are diabetic, up to several
times a day to monitor blood glucose levels
Urine glucose: usually as part of a urinalysis
Sample Required?
A blood sample drawn from a vein in your arm or, for a self check, a drop of blood from a
skin prick; sometimes a random urine sample is used. Some diabetic patients may use a
continuous glucose monitor, which is a small sensor wire inserted beneath the skin of the
abdomen that measures blood glucose every five minutes.
Test Preparation Needed?
In general, it is recommended that you fast - nothing to eat or drink except water - 8 hours
before having a blood glucose test. In persons with diabetes, however, glucose levels are
often checked both while fasting and after meals to provide the best control of diabetes.
The Test Sample
What is being tested?
Glucose is a simple sugar that serves as the main source of energy for the body. The
carbohydrates we eat are broken down into glucose (and a few other simple sugars),
absorbed by the small intestine, and circulated throughout the body. Most of the body's
cells require glucose for energy production; brain and nervous system cells not only rely
on glucose for energy, they can only function when glucose levels in the blood remain
above a certain level.
The body's use of glucose hinges on the availability of insulin, a hormone produced by the
pancreas. Insulin acts as a traffic director, transporting glucose into the body's cells,
directing the body to store excess energy as glycogen for short-term storage and/or as
triglycerides in adipose (fat) cells. We cannot live without glucose or insulin, and they
must be in balance.
Normally, blood glucose levels rise slightly after a meal, and insulin is secreted to lower
them, with the amount of insulin released matched up with the size and content of the
meal. If blood glucose levels drop too low, such as might occur in between meals or after a
strenuous workout, glucagon (another pancreatic hormone) is secreted to tell the liver to
turn some glycogen back into glucose, raising the blood glucose levels. If the
glucose/insulin feedback mechanism is working properly, the amount of glucose in the
blood remains fairly stable. If the balance is disrupted and glucose levels in the blood rise,
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then the body tries to restore the balance, both by increasing insulin production and by
excreting glucose in the urine.
Severe, acute hyperglycemia or hypoglycemia can be life-threatening, causing organ
failure, brain damage, coma, and, in extreme cases, death. Chronically high blood glucose
levels can cause progressive damage to body organs such as the kidneys, eyes, heart and
blood vessels, and nerves. Chronic hypoglycemia can lead to brain and nerve damage.
Some women may develop hyperglycemia during pregnancy, which is termed gestational
diabetes. If untreated, this can cause these mothers to give birth to large babies who may
have low glucose levels. Women who have had gestational diabetes may or may not go on
to develop diabetes.
Is any test preparation needed to ensure the quality of the sample?
For screening purposes, it is generally recommended that you fast - nothing to eat or drink
except water - at least 8 hours before a blood glucose test. Those who have been diagnosed
with diabetes and are monitoring glucose levels are often tested both while fasting and
after meals. A glucose tolerance test requires that you fast for the first blood sample and
then drink a liquid containing a specified amount of glucose. Subsequent blood samples
are drawn at specified times.
The Test
How is it used?
The blood glucose test is ordered to measure the amount of glucose in the blood right at
the time of sample collection. It is used to detect both hyperglycemia and hypoglycemia,
to help diagnose diabetes, and to monitor glucose levels in persons with diabetes. Blood
glucose may be measured on a fasting basis (collected after an 8 to 10 hour fast), randomly
(anytime), post prandial (after a meal), and/or as part of an oral glucose tolerance test
(OGTT / GTT). An OGTT is a series of blood glucose tests. A fasting glucose is collected;
then the patient drinks a standard amount of a glucose solution to "challenge" their system.
This is followed by one or more additional glucose tests performed at specific intervals to
track glucose levels over time. The OGTT may be ordered to help diagnose diabetes and
as a follow-up test to an elevated blood glucose.
The American Diabetes Association recommends either the fasting glucose or the OGTT
to diagnose diabetes but says that testing should be done twice, at different times, in order
to confirm a diagnosis of diabetes.
Most pregnant women are screened for gestational diabetes, a temporary form of
hyperglycemia, between their 24th and 28th week of pregnancy using a version of the
OGTT, a 1-hour glucose challenge. If either fasting glucose or a random glucose is above
the values used to diagnose diabetes in those who are not pregnant, the woman is
considered to have gestational diabetes and neither the screening nor the glucose tolerance
test is needed. If the 1-hour level is higher than the defined value, a longer OGTT is
performed to clarify the patient's status.
Diabetics must monitor their own blood glucose levels, often several times a day, to
determine how far above or below normal their glucose is and to determine what oral
medications or insulin(s) they may need. This is usually done by placing a drop of blood
from a skin prick onto a glucose strip and then inserting the strip into a glucose meter, a
small machine that provides a digital readout of the blood glucose level.
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In those with suspected hypoglycemia, glucose levels are used as part of the "Whipple
triad" to confirm a diagnosis. (See "Is there anything else I should know?" section).
The urine glucose is seldom ordered by itself. At one time, it was used to monitor
diabetics, but it has been largely replaced by the more sensitive and “real time” blood
glucose. The urine glucose is, however, one of the substances measured when a urinalysis
is performed. A urinalysis may be done routinely as part of a physical or prenatal checkup,
when a doctor suspects that a patient may have a urinary tract infection, or for a variety of
other reasons. The doctor may follow an elevated urine glucose test with blood glucose
testing.
When is it ordered?
Blood glucose testing can be used to screen healthy, asymptomatic individuals for diabetes
and pre-diabetes because diabetes is a common disease that begins with few symptoms.
Screening for glucose may occur during public health fairs or as part of workplace health
programs. It may also be ordered when a patient has a routine physical exam. Screening is
especially important for people at high risk of developing diabetes, such as those with a
family history of diabetes, those who are overweight, and those who are more than 40 to
45 years old.
The glucose test may also be ordered to help diagnose diabetes when someone has
symptoms of hyperglycemia, such as:
• Increased thirst
• Increased urination
• Fatigue
• Blurred vision
• Slow-healing infections
or symptoms of hypoglycemia, such as:
• Sweating
• Hunger
• Trembling
• Anxiety
• Confusion
• Blurred Vision
Blood glucose testing is also done in emergency settings to determine if low or high
glucose is contributing to symptoms such as fainting and unconsciousness. If a patient has
pre-diabetes (characterized by fasting or OGTT levels that are higher than normal but
lower than those defined as diabetic), the doctor will order a glucose test at regular
intervals to monitor the patient’s status. With known diabetics, doctors will order glucose
levels in conjunction with other tests such as hemoglobin A1c to monitor glucose control
over a period of time. Occasionally, a blood glucose level may be ordered along with
insulin and C-peptide to monitor insulin production.
Diabetics may be required to self-check their glucose, once or several times a day, to
monitor glucose levels and to determine treatment options as prescribed by their doctor.
Pregnant women are usually screened for gestational diabetes late in their pregnancies,
unless they have early symptoms or previously have had gestational diabetes. When a
woman has gestational diabetes, her doctor will usually order glucose levels throughout
the rest of her pregnancy and after delivery to monitor her condition.
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What does the test result mean?
High levels of glucose most frequently indicate diabetes, but many other diseases and
conditions can also cause elevated glucose. The following information summarizes the
meaning of the test results. These are based on the clinical practice recommendations of
the American Diabetes Association.
Fasting Blood Glucose
GLUCOSE LEVEL INDICATION

From 70 to 99 mg/dL (3.9 to 5.5 mmol/L) Normal fasting glucose
From 100 to 125 mg/dL (5.6 to 6.9 mmol/L) Impaired fasting glucose (pre-
diabetes)
126 mg/dL (7.0 mmol/L) and above on more than one Diabetes
testing occasion
Oral Glucose Tolerance Test (OGTT)
Levels applicable except during pregnancy. Sample drawn 2 hours after a 75-gram glucose
drink.

Less than 140 mg/dL (7.8 mmol/L) Normal glucose tolerance
From 140 to 200 mg/dL (7.8 to 11.1 mmol/L) Impaired glucose tolerance (pre-
diabetes)
Over 200 mg/dL (11.1 mmol/L) on more than one Diabetes
testing occasion
Gestational Diabetes Screening: Glucose Challenge Test
Sample drawn 1 hour after a 50-gram glucose drink.

Less than 140* mg/dL (7.8 mmol/L) Normal screen
140* mg/dL (7.8 mmol/L) and over Abnormal, needs OGTT (see below)
* Some use a cutoff of 130 mg/dL (7.2 mmol/L) because that identifies 90% of women
with gestational diabetes, compared to 80% identified using the threshold of 140 mg/dL
(7.8 mmol/L).
Gestational Diabetes Diagnostic: OGTT
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Sample drawn after 100-gram glucose drink (glucose load).
TIME OF SAMPLE COLLECTION TARGET LEVEL

Fasting* (prior to glucose load) 95 mg/dL (5.3 mmol/L)
1 hour after glucose load 180 mg/dL (10.0 mmol/L)
2 hours after glucose load 155 mg/dL (8.6 mmol/L)
3 hours after glucose load* 140 mg/dL (7.8 mmol/L
INDICATION: If two or more values meet or exceed the target level, gestational diabetes
is diagnosed.
* A 75-gram glucose load may be used, although this method is not as well validated as
the 100-gram OGTT; the 3-hour sample is not drawn if 75 grams is used.
Some of the other diseases and conditions that can result in elevated glucose levels
include:
• Acromegaly
• Acute stress (response to trauma, heart attack, and stroke for instance)
• Chronic renal failure
• Cushing syndrome
• Drugs, including: corticosteroids, tricyclic antidepressants, diuretics, epinephrine,
estrogens (birth control pills and hormone replacement), lithium, phenytoin
(Dilantin), salicylates,
• Excessive food intake
• Hyperthyroidism
• Pancreatic cancer
• Pancreatitis
Low to non-detectible urine glucose results are considered normal. Anything that raises
blood glucose levels also has the potential to elevate urine glucose levels. Increased urine
glucose levels may be seen with medications, such as estrogens and chloral hydrate, and
with some forms of renal disease.
Moderately increased blood levels may be seen with pre-diabetes. This condition, if left
un-addressed, often leads to type 2 diabetes.
Low blood glucose levels (hypoglycemia) are also seen with:
• Adrenal insufficiency
• Drinking alcohol
• Drugs, such as acetaminophen and anabolic steroids
• Extensive liver disease
• Hypopituitarism
• Hypothyroidism
• Insulin overdose
• Insulinomas
• Starvation
Is there anything else I should know?
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Hypoglycemia is characterized by a drop in blood glucose to a level where first it causes
nervous system symptoms (sweating, palpitations, hunger, trembling, and anxiety), then
begins to affect the brain (causing confusion, hallucinations, blurred vision, and
sometimes even coma and death). An actual diagnosis of hypoglycemia requires satisfying
the "Whipple triad." These three criteria include:
• Documented low glucose levels (less than 40 mg/dL (2.2 mmol/L) often tested
along with insulin levels and sometimes with C-Peptide levels)
• Symptoms of hypoglycemia
• Reversal of the symptoms when blood glucose levels are returned to normal.
Primary hypoglycemia is rare and often diagnosed in infancy. People may have symptoms
of hypoglycemia without really having low blood sugar. In such cases, dietary changes
such as eating frequent small meals and several snacks a day and choosing complex
carbohydrates over simple sugars may be enough to ease symptoms. Those with fasting
hypoglycemia may require IV glucose if dietary measures are insufficient.
Common Questions
1. Can I test myself at home for blood glucose levels?
If you are not diabetic or pre-diabetic, there is usually no reason to test glucose levels at
home. Screening done as part of your regular physical should be sufficient.
If you have been diagnosed with diabetes, however, your doctor or diabetes educator will
recommend a home glucose monitor (glucometer, or one of the newer methods that uses
very tiny amounts of blood or tests the interstitial fluid -- the fluid between your cells --
for glucose). You will be given guidelines for how high or low your blood sugar should be
at different times of the day. By checking your glucose regularly, you can see if the diet
and medication schedule you are following is working properly for you.
2. Can I test my urine glucose instead of my blood?
Not in most cases. Glucose will usually only show up in the urine if it is at sufficiently
high levels in the blood so that the body is "dumping" the excess into the urine, or if there
is some degree of kidney damage and the glucose is leaking out into the urine. Urine
glucose, however, is sometimes used as a rough indicator of high glucose levels and the
urine indicator strip (dipstick) that measures the glucose is occasionally useful for tracking
the presence of protein and ketones in the urine.
3. What are the usual treatments for diabetes?
For type 2 diabetes, which is the most common type of diabetes, losing excess weight,
eating a healthy diet that is high in fiber and restricted in carbohydrates, and getting
regular amounts of exercise may be enough to lower your blood glucose levels. In many
cases, however, oral medications that increase the body's secretion of and sensitivity to
insulin are necessary to achieve the desired glucose level. With type 1 diabetes (and with
type 2 diabetes that does not respond well enough to oral medications), insulin injections
several times a day are necessary.
4. How can a diabetic educator help me?
If you are diabetic, a diabetic educator (often a nurse with specialized training) can make
sure that you know how to:
• Recognize and know how to treat both high and low blood sugar.
• Test and record your self-check glucose values.
• Adjust your medications.
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• Administer insulin (which types in which combinations to meet your needs).
• Handle medications when you get ill.
• Monitor your feet, skin, and eyes to catch problems early.
• Buy diabetic supplies and store them properly.
• Plan meals. Diet is extremely important in minimizing swings in blood glucose
levels. A registered dietician can help you learn how to plan meals and a diabetic
educator can help with this as well.
Uric Acid
Formal name: Uric Acid
Why Get Tested?
To detect high levels of uric acid, which could be a sign of the condition gout, or to
monitor uric acid levels when undergoing chemotherapy or radiation treatment
When to Get Tested?
When monitoring certain chemotherapy or radiation therapies for cancer; when you have
joint pain or other symptoms that your doctor suspects may be due to gout
Sample Required?
A blood sample drawn from a vein in the arm
Uric acid is produced by the breakdown of purines. Purines are chemicals that come from
nucleic acids (DNA). They enter the circulation from digestion of foods or from normal
breakdown and turnover of cells in the body. Most uric acid is removed by the kidneys and
disposed of in the urine; the remainder is excreted in the feces.
If too much uric acid is produced or not enough is excreted, it can accumulate. The
presence of excess uric acid can cause the condition called gout – an inflammation that
occurs in joints when crystals derived from uric acid form in the joint fluid.
The most common reasons for accumulation of uric acid are an inherited tendency to
overproduce uric acid or impaired kidney function that results in decreased ability to
excrete uric acid.
The Test
How is it used?
The uric acid test is used to learn whether the body might be breaking down cells too
quickly or not getting rid of uric acid quickly enough. The test also is used to monitor
levels of uric acid when a patient has had chemotherapy or radiation treatments.
When is it ordered?
The uric acid test is ordered when a doctor suspects high levels of uric acid. Some patients
with high levels of uric acid have a disease called gout, which is an inherited disorder that
affects purine breakdown. Patients with gout suffer from joint pain, most often in their toes
but in other joints as well. The test also is ordered as a monitoring test when a patient has
undergone chemotherapy or radiation, to learn whether uric acid levels are getting
dangerously high. The test may also be ordered if a patient appears to have failing kidneys.
Patients who have high uric acid levels are sometimes put on a drug regimen to help lower
uric acid levels.
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Higher than normal uric acid levels mean that the body is not handling the breakdown of
purines well. The doctor will have to learn whether the cause is the over-production of uric
acid, or if the body is unable to clear away the uric acid.
Increased concentrations of uric acid can cause crystals to form in the joints, which leads
to the joint inflammation and pain characteristic of gout. Uric acid can also form crystals
or kidney stones that can damage the kidneys.
Low levels of uric acid in the blood are seen much less commonly than high levels and are
seldom considered cause for concern. Although low values can be associated with some
kinds of liver or kidney diseases, exposure to toxic compounds, and rarely as the result of
an inherited metabolic defect, these conditions are typically identified by other tests and
symptoms and not by an isolated low uric acid result.
Many drugs can increase or decrease the level of uric acid. In particular, diuretic drugs like
thiazide drugs can cause uric acid levels to go up.
Aspirin (and other salicylates) have varying effects on uric acid. At low aspirin levels (as
may occur in persons taking aspirin only occasionally), aspirin can increase blood uric
acid. On the other hand, in high doses (as may be used to treat rheumatoid arthritis),
aspirin actually lowers the concentration of uric acid.
For people who have uric acid kidney stones or gout, foods that are high in purine content
should be avoided, including organ meats (like liver and kidneys), sardines and anchovies.
Alcohol also should be avoided, because it slows down the removal of uric acid from the
body. Fasting, a starvation diet, and strenuous exercise all raise uric acid levels.
Although the uric acid test cannot definitively diagnose gout, a test for monosodium urate
in synovial fluid (joint fluid) can.
Common Questions
1. If I have high levels of uric acid, can they be lowered easily or will I have to take
drugs for the rest of my life?
Depending on the condition that causes your high levels of uric acid, you may not need to
take drugs. If you have a sudden attack caused by high uric acid, as with an attack of gout,
your doctor may treat you with the drug colchicine and a nonsteroidal anti-inflammatory
drug, such as aspirin or ibuprofen. This treatment usually is short-term.
However, you may have to stay on a maintenance therapy for a few years, until your uric
acid levels come under control. You may be given drugs that help to rid your system of
uric acid salts, such as probenecid, or you may be given drugs that interfere with uric acid
production, such as allopurinol.
If you have had chemotherapy or radiation, you may have to take uric acid tests more
often and possibly treat the condition over time.
2. What is gout?
Gout is one of the most common forms of arthritis. A gout attack usually happens at night,
and within 12 or so hours there may be severe pain and swelling in the joint. Gout usually
affects only one or two joints at the same time, typically in the feet and ankles. It often
occurs in the big toe, and people can notice it at night when their bedding rubs on their toe
and causes extreme pain. Gout happens when crystals derived from uric acid accumulate
in the joints. These crystals cause inflammation.
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Without treatment, an early attack of gout usually goes away in a week. It may be months
or years until the next attack. As time goes on, more joints can become affected and the
disease may cause disabilities or eventually cripple the patient, according to the American
College of Rheumatology. That is why it is important to get treated right away if you think
you may have gout. Your doctor will order a uric acid test and may have to take fluid from
the joint through a needle to look for the microscopic crystals.
3. I heard women don’t get gout. Is that true?

No. Gout affects mostly men, and it is very rare in women until after menopause, the time
in life when a woman’s monthly period stops.
Triglycerides
Also known as: TG; TRIG
Formal name: Triglycerides
Related tests: Cholesterol; HDL-C; LDL-C; Direct LDL-C; VLDL-C; Lipid profile;
Cardiac Risk Assessment
Why Get Tested?
To assess the risk of developing heart disease
When to Get Tested?
As part of a lipid profile during a regular medical exam, if you have risk factors for heart
disease or if you are being treated for high triglycerides
Sample Required?
A blood sample drawn from a vein or a fingerstick
Current standards recommend that testing be done when you are fasting. For 9 to 12 hours
before the test, only water is permitted. In addition, alcohol should not be consumed for 24
hours just before the test.
This test measures the amount of triglycerides in your blood. Triglycerides are a form of
fat and a major source of energy for the body. Most triglycerides are found in fat (adipose)
tissue, but some triglycerides circulate in the blood to provide fuel for muscles to work.
After you eat, increased levels of triglycerides are found in the blood as your body
converts the energy you don’t need right away into fat. Triglycerides move via the blood
from the gut to adipose tissue for storage. In between meals, triglycerides are released
from fat tissue to be used as an energy source for the body. Most triglycerides are carried
in the blood by lipoproteins called very low density lipoproteins (VLDL).
High levels of triglycerides in the blood are associated with an increased risk of
developing cardiovascular disease (CVD), although the reason for this is not well
understood. Certain factors can contribute to high triglyceride levels and to your risk of
CVD, including lack of exercise, being overweight, smoking cigarettes, consuming excess
alcohol, and medical conditions such as diabetes and kidney disease.
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Current standards recommend that testing be done when you are fasting. For 9 to 12 hours
before the test, only water is permitted. In addition, alcohol should not be consumed for 24
hours just before the test.
The Test
How is it used?
Blood tests for triglycerides are usually part of a lipid profile used to identify the risk of
developing heart disease. As part of a lipid profile, it may be used to monitor those who
have risk factors for heart disease, those who have had a heart attack, or those who are
being treated for high lipid and/or triglyceride levels.
Some risk factors for heart disease include:
• Cigarette smoking
• Age (men 45 years or older or women 55 years or older)
• Hypertension (blood pressure of 140/90 or higher or taking high blood pressure
medications)
• Family history of premature heart disease (heart disease in an immediate family
member—male relative under age 55 or female relative under age 65)
• Diabetes mellitus
If you are diabetic, it is especially important to have triglycerides measured as part of any
lipid testing since triglycerides increase significantly when blood sugar levels are not well-
controlled.
When is it ordered?
Lipid profiles, including triglycerides, are recommended every 5 years to evaluate risk of
heart disease in healthy adults. The test for triglycerides is not often ordered alone since
risk of heart disease is based also on cholesterol levels (see total cholesterol, HDL-C,
LDL-C). Testing may be ordered more frequently for people who have identified risk
factors for heart disease or who have been found to have high triglycerides and are being
treated for it, to monitor treatment.
For children and adolescents at low risk, triglyceride and/or lipid testing is usually not
ordered routinely. However, screening with a lipid profile is recommended for children
and youths who are at an increased risk of developing heart disease as adults. Some of the
risk factors are similar to those in adults and include a family history of heart disease or
health problems such as diabetes, high blood pressure, or being overweight. High-risk
children should have their first lipid profile between 2 and 10 years old, according to the
American Academy of Pediatrics. Children younger than 2 years old are too young to be
tested.
A triglyceride test is usually performed as part of a fasting lipid profile, and your doctor
will take into consideration the results of each component of the lipid panel.
For adults, triglyceride test results are categorized as follows:
• Desirable: Less than 150 mg/dL (1.7 mmol/L)
• Borderline high: 150 to 199 mg/dL (1.7-2.2 mmol/L)
• High: 200 to 499 mg/dL (2.3-5.6 mmol/L)
• Very high: Greater than 500 mg/dL (5.6 mmol/L)
Note: These values are based on fasting triglyceride levels.
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High triglyceride levels are associated with an increased risk of developing heart disease.
Elevated levels can be due to several causes including:
• Being physically inactive, overweight, and/or obese
• Increased alcohol consumption
• Conditions such as type 2 diabetes or kidney disease
• Hypothyroidism
• Genetic factors
When triglycerides are very high (greater than 1000 mg/dL (11.30 mmol/L)), there is a
risk of developing pancreatitis. Treatment to lower triglycerides should be started as soon
as possible.
The categories for triglyceride results for children and adolescents are different than those
for adults. Talk to your child’s pediatrician about your child’s results.
If you are diabetic and your blood sugar is out of control, triglycerides may be very high.
Triglycerides change dramatically in response to meals, increasing as much as 5 to 10
times higher than fasting levels just a few hours after eating. Even fasting levels vary
considerably day to day. Therefore, modest changes in fasting triglycerides measured on
different days are not considered to be abnormal.
Certain drugs such as corticosteroids, protease inhibitors for HIV, beta blockers, and
estrogens can increase blood triglyceride levels.
There is increasing interest in measuring triglycerides in people who have not fasted. The
reason is that a non-fasting sample may be more representative of the “usual” circulating
level of triglyceride since most of the day blood lipid levels reflect post-meal (post-
prandial) levels rather than fasting levels. However, it is not yet certain how to interpret
non-fasting levels for evaluating risk so at present there is no change in the current
recommendations for fasting prior to tests for lipid levels.
Common Questions
1. What strategies can be used to lower triglyceride levels?
For many people, high triglycerides are caused by another disorder such as diabetes,
obesity, renal failure, or alcoholism. With these conditions, the strategy is to treat the
primary cause. When high triglycerides are not caused by another disorder, they are often
seen together with high cholesterol, and treatment is directed toward lowering both
cholesterol and triglycerides. Lifestyle changes such as a healthy diet and increased
exercise are usually the primary strategy for lowering levels. If these fail, lipid-lowering
medications such as statins are generally recommended. For more on this, visit the
American Heart Association’s webpage on Diet and Lifestyle Recommendations.
2. Can I monitor triglyceride levels at home?
A few products are available to test lipid levels, including triglycerides, at home. There are
two types of home testing: those where you collect the sample at home and then mail it
away to a laboratory for testing and those where you conduct the test yourself at home
(self-monitoring). The American Heart Association hasn’t taken a position on the use of
home testing devices for measuring lipid levels. Before making the decision to use one of
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these products, you may want to review the article about home testing on this site: With
Home Testing, Consumers Take Charge of Their Health.
3. What is VLDL and how does it relate to triglyceride?
Very Low Density Lipoprotein (VLDL) is one of three major lipoprotein particles. The
other two are high density lipoprotein (HDL) and low density lipoprotein (LDL). Each one
of these particles contains a mixture of cholesterol, protein, and triglyceride, but in varying
amounts unique to each type of particle. LDL contains the highest amount of cholesterol.
HDL contains the highest amount of protein. VLDL contains the highest amount of
triglyceride. Since VLDL contains most of the circulating triglyceride and since the
compositions of the different particles are relatively constant, it is possible to estimate the
amount of VLDL-cholesterol by dividing the triglyceride value (in mg/dL) by 5. At
present, there is no simple, direct way of measuring VLDL-cholesterol, so the estimate
calculated from triglyceride is used in most settings. This calculation is not valid when the
triglyceride is greater than 400 mg/dL. Increased levels of VLDL-cholesterol have been
found to be associated with increased risk of heart disease and stroke.
Total Protein and A/G Ratio

Also known as: TP; Albumin/Globulin ratio
Formal name: Total Protein; Albumin/Globulin ratio
Related tests: Albumin; Liver panel; Protein electrophoresis
Why Get Tested?
As part of a general health checkup, to determine your nutritional status or to screen for
certain liver and kidney disorders as well as other diseases
When to Get Tested?
When you have a routine physical exam or if you experience unexpected weight loss or
fatigue or if your doctor thinks that you have symptoms of a liver or kidney disorder
Sample Required?
A blood sample drawn from a vein in your arm or by fingerstick (adults and children) or
heelstick (newborns)
None
Proteins are important building blocks of all cells and tissues; they are important for body
growth, development, and health. They form the structural part of most organs and make
up enzymes and hormones that regulate body functions. This test measures the total
amount of the various types of proteins in the plasma portion of your blood.
There are two classes of proteins, albumin and globulin, found in the blood. Albumin is a
carrier of many small molecules, but its main purpose is to keep fluid from leaking out of
blood vessels through osmotic pressure. Globulin proteins include enzymes, antibodies,
and more than 500 other proteins. The ratio of albumin to globulin (A/G ratio) is
calculated from values obtained by direct measurement of total protein and albumin. It
represents the relative amounts of albumin and globulins.
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No test preparation is needed.
The Test
How is it used?
Total protein measurements can reflect nutritional status and may be used to screen for and
help diagnose kidney disease, liver disease, and many other conditions. Sometimes
conditions are first detected with routine testing before symptoms have begun to appear. If
total protein is abnormal, further tests must be performed to identify which specific protein
is abnormally low or high so that a specific diagnosis can be made.
When is it ordered?
A total protein test is one component of a Comprehensive Metabolic Panel (CMP) that is
often ordered as part of a routine health checkup. Total protein may also be ordered to
provide general information about your nutritional status, such as when you have
undergone a recent weight loss. It can be ordered along with several other tests to provide
information if you have symptoms that suggest a liver or kidney disorder or to investigate
the cause of abnormal pooling of fluid in tissue (edema).
Results of a total protein test will give your doctor information on your general health
status with regard to your nutrition and/or conditions involving major organs, such as the
kidney and liver. However, if results are abnormal, further testing is usually required to
help diagnose the disease affecting protein levels in the blood.
Low total protein levels can suggest a liver disorder, a kidney disorder, or a disorder in
which protein is not digested or absorbed properly. Low levels may be seen in severe
malnutrition and with conditions that cause malabsorption, such as Celiac disease or
inflammatory bowel disease (IBD).
High total protein levels may be seen with chronic inflammation or infections such as viral
hepatitis or HIV. They may be caused by bone marrow disorders such as multiple
myeloma.
Some laboratories also report the calculated ratio of albumin to globulins, termed the A/G
ratio. Normally, there is a little more albumin than globulins, giving a normal A/G ratio of
slightly over 1. Because disease states affect the relative changes in albumin and globulins
in different ways, this may provide a clue to your doctor as to the cause of the change in
protein levels. A low A/G ratio may reflect overproduction of globulins, such as seen in
multiple myeloma or autoimmune diseases, or underproduction of albumin, such as occurs
with cirrhosis, or selective loss of albumin from the circulation, as occurs with kidney
disease (nephrotic syndrome). A high A/G ratio suggests underproduction of
immunoglobulins as may be seen in some genetic deficiencies and in some leukemias.
More specific tests, such as albumin, liver enzyme tests, and serum protein electrophoresis
must be performed to make an accurate diagnosis.
Prolonged application of a tourniquet during blood collection can result in a blood sample
that has a higher protein concentration than the rest of the circulation. This will mean that
the test result for total protein will be falsely elevated (higher than the actual concentration
in the circulation).
Drugs that may decrease protein levels include estrogens and oral contraceptives.
13
Common Questions
1. Will a high protein diet raise my total protein level?
No, increasing your intake of protein will not increase your total protein test result.
2. What type of nutrition is recommended for optimal protein levels?
A well-balanced diet that follows the recommendations of the United States Department of
Agriculture is summarized by the Food Pyramid.
Cholesterol
Also known as: Blood cholesterol
Formal name: Total cholesterol
Related tests: HDL-C, LDL-C, Triglycerides, Lipid profile, Cardiac risk assessment
Why Get Tested?
To screen for risk of developing heart disease
When to Get Tested?
Adults should be tested once every five years or more frequently if being treated for high
cholesterol or have one or more risk factors for heart disease. Children and adolescents
with risk factors should also have their cholesterol level checked.
Sample Required?
A blood sample drawn from a vein in the arm or a fingerstick
If you are having this test performed as part of the Lipid profile, you will need to fast for
9-12 hours before the sample is collected; only water is permitted.
Cholesterol is a substance (a steroid) that is essential for life. It forms the membranes for
cells in all organs and tissues in your body. It is used to make hormones that are essential
for development, growth, and reproduction. It forms bile acids that are needed to absorb
nutrients from food. A small amount of your body’s cholesterol circulates in the blood in
complex particles called lipoproteins. These lipoproteins include some particles that carry
excess cholesterol away for disposal (see HDL-C, good cholesterol) and some particles
that deposit cholesterol in tissues and organs (see LDL-C, bad cholesterol). The test for
cholesterol measures total cholesterol (good and bad) that is carried in the blood by
lipoproteins.
Your body produces the cholesterol needed to work properly, but the source for some
cholesterol is your diet. If you have an inherited predisposition for high cholesterol levels
or if you eat too much of the foods that are high in cholesterol, saturated fats, and trans
unsaturated fats (trans fats), then levels of cholesterol in your blood may increase and have
a negative impact on your health. The extra cholesterol in your blood may be deposited in
plaques on the walls of blood vessels. Plaques can narrow or eventually block the opening
of blood vessels, leading to hardening of the arteries (atherosclerosis) and increasing your
risk of numerous health problems, including heart disease and stroke.
Monitoring and maintaining healthy levels of cholesterol is important in staying healthy.
14
If a cholesterol test is to be performed alone, it is not necessary to fast. However, if it is to
be performed as part of a lipid profile, as it often is, then fasting for 9-12 hours before the
test will be required; only water is permitted.
The Test
How is it used?
Cholesterol is different from most tests in that it is not used to diagnose or monitor a
disease but is used to estimate risk of developing a disease — specifically heart disease.
Because high blood cholesterol has been associated with hardening of the arteries
(atherosclerosis), heart disease, and a raised risk of death from heart attacks, cholesterol
testing is considered a routine part of preventive health care.
When is it ordered?
Cholesterol testing is recommended as a screening test to be done on all adults at least
once every five years. It is frequently done in conjunction with a routine physical exam. It
is usually ordered in combination with other tests including HDL-C, LDL-C, and
triglycerides — often called a lipid profile.
Cholesterol is tested at more frequent intervals (often several times per year) in patients
who have been prescribed diet and/or drugs to lower their cholesterol. The test is used to
track how well these measures are succeeding in lowering cholesterol to desired levels and
in turn lowering the risk of developing heart disease.
Cholesterol testing may be ordered more frequently for those who have one or more risk
factors for heart disease. Major risk factors include:
• Age (men 45 years or older or women 55 years or older)
• Hypertension (blood pressure of 140/90 or higher or taking high blood pressure
medications)
• Family history of premature heart disease (heart disease in an immediate family
member—male relative under age 55 or female relative under age 65)
• Pre-existing heart disease or already having had a heart attack
For those under 20 years of age and at low risk, cholesterol testing is usually not ordered
routinely. However, screening for high cholesterol as part of a lipid profile is
recommended for children and youths who are at an increased risk of developing heart
disease as adults. Some of the risk factors are similar to those in adults and include:
• Family history—history of high cholesterol or heart disease in close relatives,
particularly if occurring before age 55 in women or 65 in men. If the family history
is not known, a cholesterol test is recommended, especially if other risk factors are
present.
• Being overweight or obese—when the youth’s body mass index (BMI) is at or
above the 85th percentile, cholesterol testing is recommended. The BMI should be
calculated at least once a year by the youth’s health care provider. For an obese
youth (one whose BMI is at or above the 95th percentile), laboratory tests to
measure cholesterol levels may be recommended every 2 years.
• Consuming excessive amounts of cholesterol, saturated fats, and trans fats
• High blood pressure (hypertension)
15
• Smoking cigarettes
High-risk children should have their first cholesterol test between 2 and 10 years old,
according to the American Academy of Pediatrics. Children younger than 2 years old are
too young to be tested. If the initial results are not worrisome, the fasting test should be
done again in three to five years.
For adults, in a routine setting where testing is done to screen for risk, the test results are
grouped in three categories of risk:
• Desirable: A cholesterol below 200 mg/dL (5.18 mmol/L) is considered desirable
and reflects a low risk of heart disease.
• Borderline high: A cholesterol of 200 to 239 mg/dL (5.18 to 6.18 mmol/L) is
considered to reflect moderate risk. Your doctor may decide to order a lipid profile
to see if your high cholesterol is due to the amount of bad cholesterol (high LDL-C)
or good cholesterol (high HDL-C) in your blood. Depending on the results of the
lipid profile (and any other risk factors you may have), your doctor will decide what
to do.
• High Risk: A cholesterol greater than or equal to 240 mg/dL (6.22 mmol/L) is
considered high risk. Your doctor may order a lipid profile (as well as other tests) to
try to determine the cause of your high cholesterol. Once the cause is known, an
appropriate treatment will be prescribed.
The risk categories for children and adolescents are different than adults. Talk to your
child’s pediatrician about your child’s results.
In a treatment setting, testing is used to see how much cholesterol is decreasing as a result
of treatment. The goal for the amount of change or the final (target) value will be set by
your doctor. The target value is usually based on LDL-C.
Cholesterol should be measured when a person is not ill. Blood cholesterol is temporarily
low during acute illness, immediately following a heart attack, or during stress (like from
surgery or an accident). You should wait at least 6 weeks after any illness to have
cholesterol measured.
There is some debate about whether very low cholesterol is bad. Low cholesterol (less
than 100 mg/dL (2.59 mmol/L)) is often seen when there is an existing problem like
malnutrition, liver disease, or cancer. However there is no evidence that low cholesterol
causes any of these problems.
Cholesterol is high during pregnancy. Women should wait at least six weeks after the baby
is born to have cholesterol measured.
Some drugs that are known to increase cholesterol levels include anabolic steroids, beta
blockers, epinephrine, oral contraceptives, and vitamin D.
Common Questions
1. What causes high cholesterol?
High cholesterol may be the result of an inherited disease or it may result from a diet high
in saturated fats. For many people, it is caused by a combination of both a diet high in
cholesterol, saturated fats, and trans fats and an inherited tendency towards high
cholesterol.
16
2. What treatments are recommended if my levels are too high?
The preferred treatment is to adopt a lifestyle that will help lower your levels, one
including exercise and a diet that is low in cholesterol, saturated fats, and trans fat. A low-
fat diet will usually lower cholesterol about 8%. If diet and exercise alone cannot lower
cholesterol enough, drugs are often recommended and usually aim to lower LDL-C levels
specifically. Sometimes, two different drugs are used together to treat people with
extremely high cholesterol levels. The drug of choice differs for different people although
the most commonly used lipid-lowering drugs are statins. Other drugs that may be
prescribed include bile acid sequestrants, niacin, and fibrates. Your doctor will need to
take into account your individual situation before prescribing any cholesterol-lowering
drug.
3. What is my risk of a heart attack if I have high cholesterol?
High cholesterol increases your risk of a heart attack. The higher the cholesterol, the
higher the risk. However, many other factors also affect your risk of a heart attack, such as
smoking, diabetes, age, and high blood pressure. For more information on related risk
factors, please read the American Heart Association’s section on cholesterol, “Am I At
Risk?”
4. I haven't changed my diet or exercise pattern but my cholesterol has gone up since
the last time it was tested. Why?
Cholesterol levels fluctuate over time. The measured cholesterol level may differ by as
much as 10% from one month to another. It may go up sometimes or it may go down
sometimes. These changes are called biological variation and they represent normal
variability inherent in human metabolism.
5. My doctor told me I had a high cholesterol test but instead of treating me he told
me to wait a few months and test it again. Why?
Cholesterol levels fluctuate over time. A single measurement of cholesterol may not
always reflect the "usual” cholesterol level. For this reason, it is advisable to have at least
two different measurements several weeks to several months apart before beginning any
kind of treatment. Treatment is based on the average value.
Albumin
Also known as: ALB
Formal name: Albumin
Related tests: Prealbumin, Microalbumin, Urinalysis, Liver panel
Why Get Tested?
To screen for a liver disorder or kidney disease or to evaluate nutritional status, especially
in hospitalized patients, along with or instead of a prealbumin test
When to Get Tested?
When your doctor thinks that you have symptoms of a liver disorder or kidney disease;
sometimes when you have an unintended weight loss, have symptoms associated with
malnutrition, or prior to a planned surgery
Sample Required?
A blood sample drawn from a vein in your arm
17
None
This test measures the level of albumin in the blood. Albumin is the most abundant protein
in the fluid portion of the blood, the plasma. It keeps fluid from leaking out of blood
vessels; nourishes tissues; and transports hormones, vitamins, drugs, and ions like calcium
throughout the body. Albumin is made in the liver and is extremely sensitive to liver
damage. The concentration of albumin drops when the liver is damaged, when a person
has a kidney disease that causes nephrotic syndrome, when a person is malnourished, has
inflammation, or is in shock. Albumin levels can rise when a person is dehydrated. This is
a relative increase that occurs as the volume of plasma decreases.
The Test
How is it used?
Since albumin is low in many different diseases and disorders, albumin testing is used in a
variety of settings to help diagnose disease, to monitor changes in health status with
treatment or with disease progression, and as a screen that may indicate the need for other
kinds of testing.
An albumin test may be ordered as part of a liver panel to evaluate liver function, along
with a creatinine and BUN (Blood Urea Nitrogen) to evaluate kidney function, or along
with a prealbumin to evaluate a person's nutritional status.
When is it ordered?
A physician may order an albumin test, along with other tests, when a person has
symptoms of a liver disorder such as jaundice, fatigue, or weight loss, or symptoms of
nephrotic syndrome such as swelling around the eyes, belly, or legs.
Doctors may also order blood albumin tests along with or instead of a prealbumin test
when they want to check or monitor a person's nutritional status. Albumin concentrations
do not change as rapidly as prealbumin, but decreases can reflect protein deficiencies and
malnutrition.
Low albumin levels can suggest liver disease. Other liver enzyme tests are ordered to
determine exactly which type of liver disease.
Low albumin levels can reflect diseases in which the kidneys cannot prevent albumin from
leaking from the blood into the urine and being lost. In this case, the amount of albumin or
protein in the urine also may be measured (see microalbumin).
Low albumin levels can also be seen in inflammation, shock, and malnutrition.
Low albumin levels may be seen with conditions in which the body does not properly
absorb and digest protein, such as Crohn's disease or celiac disease, or in which large
volumes of protein are lost from the intestines.
High albumin levels can be seen with dehydration, although the test is not typically used
to monitor or detect this condition.

Certain drugs increase albumin in the blood, including anabolic steroids, androgens,
growth hormones, and insulin.
18
If someone is receiving large amounts of intravenous fluids, the results of this test may be
inaccurate.
Common Questions
1. Is anyone at high risk for abnormal albumin levels?
Individuals who have chronic liver disease and kidney disorders are at highest risk for
developing abnormal albumin levels. In addition, individuals whose GI tract doesn't
absorb nutrients properly and individuals who have prolonged diarrhea can develop
abnormal albumin levels.
2. Is there a home test for albumin levels?
No, not for blood albumin. You can test for high albumin levels in urine with a dipstick
purchased in a drug store.
3. What is the difference between albumin, prealbumin, and microalbumin tests?
Albumin and microalbumin are the same molecule while prealbumin, despite the similar-
sounding name, is a completely unrelated molecule. The prealbumin test measures a
protein that reflects your current nutritional status, particularly before and after surgery, or
if you are hospitalized or taking nutritional supplements. Albumin testing is more often
used to test for liver or kidney disease or to learn if your body is not absorbing enough
amino acids. Albumin can also be used to monitor nutritional status and is a more widely
available test than prealbumin. However, prealbumin changes more quickly, making it
more useful for detecting changes in short-term nutritional status than albumin. The
microalbumin test measures very small levels of albumin in your urine and may indicate
whether you are at risk for developing kidney disease.
Hemoglobin
Also known as: Hgb; Hb
Formal name: Hemoglobin
Related tests: Complete blood count
Why Get Tested?
If you have anemia or polycythemia, to assess the severity of these conditions, and to
monitor response to treatment
When to Get Tested?
Usually, as part of a complete blood count (CBC), which may be ordered for a variety of
reasons
Sample Required?
A blood sample drawn from a vein in your arm or by a fingerstick (children and adults) or
heelstick (newborns)
None

This test measures the amount of hemoglobin, a protein found in red blood cells, in a
blood sample, which is a good indication of the blood’s ability to deliver oxygen to tissues
and organs and to transport the waste product carbon dioxide to the lungs, where it is
19
exhaled. If your hemoglobin levels are low, you may have anemia, a condition in which
your body is not getting enough oxygen, causing fatigue and weakness.
The hemoglobin rises when the number of red blood cells increases. The hemoglobin falls
to less than normal, indicating anemia, when your body decreases its production of red
blood cells, increases its destruction of red blood cells, or if blood is lost due to bleeding.
The Test
How is it used?
The hemoglobin test is an integral part of your health evaluation. The test is used to:
• measure the severity of anemia or polycythemia,
• monitor the response to treatment of anemia or polycythemia, and
• help make decisions about blood transfusions if the anemia is severe.
When is it ordered?
The hemoglobin test is normally ordered as a part of the complete blood count (CBC) ,
which is ordered for many different reasons, including for a general health screen. The test
is also repeated in patients who have ongoing bleeding problems or chronic anemias or
polycythemia.
Normal values in an adult are 12 to 18 grams per deciliter (100 milliliters) of blood.
Above-normal hemoglobin levels may be the result of:
• dehydration,
• excess production of red blood cells in the bone marrow,
• severe lung disease, or
• several other conditions.
Below-normal hemoglobin levels may lead to anemia that can be the result of:
• iron deficiency or other deficiencies, such as B12 and folate,
• inherited hemoglobin defects, such as sickle cell anemia or thalassemias,
• other inherited conditions, such as enzyme defects,
• cirrhosis of the liver,
• excessive bleeding,
• excessive destruction of red blood cells,
• kidney disease,
• other chronic illnesses,
• bone marrow failure or aplastic anemia, or
• cancers that affect the bone marrow.
Hemoglobin decreases slightly during normal pregnancy.
Hemoglobin levels peak around 8 a.m. and are lowest around 8 p.m. each day.
Heavy smokers have higher hemoglobin levels than nonsmokers.
Living in high altitudes increases hemoglobin values due to an increase in the number of
red blood cells. Your body produces more red blood cells in response to the decreased
oxygen available at these heights.
Hemoglobin levels are slightly lower in older men and women and in children.
20
Common Questions
1. Does exercise affect hemoglobin levels?
No, except that dehydration can temporarily increase hemoglobin levels.
2. Is anyone at greater risk of abnormal hemoglobin levels?
Women of childbearing age may have temporary decreases during menstrual periods and
pregnancy.
3. Are there warning signs for abnormally low hemoglobin levels?
Some warning signs are fatigue, fainting, pallor, and shortness of breath.
4. Can a healthy diet and nutrition help keep optimal hemoglobin levels?
A healthy diet containing vegetables and foods high in iron can be beneficial.
ALT
Also known as: Serum glutamic-pyruvic transaminase; SGPT; Alanine transaminase;
AST/ALT ratio
Formal name: Alanine aminotransferase
Related tests: AST; ALP; GGT; Bilirubin; Liver panel; Albumin; Total Protein
Why Get Tested?
To screen for liver damage and/or to help diagnose liver disease
When to Get Tested?
When your doctor thinks that you have symptoms of a liver disorder
Sample Required?
None
Alanine aminotransferase (ALT) is an enzyme found mostly in the cells of the liver and
kidney; much smaller amounts of it are also found in the heart and muscles. In healthy
individuals, ALT levels in the blood are low. When the liver is damaged, ALT is released
into the blood stream, usually before more obvious symptoms of liver damage occur, such
as jaundice. This makes ALT a useful test for detecting liver damage.
The liver is a vital organ located in the upper right-hand side of the abdominal area. It is
involved in many important functions in the body. The liver helps to process the body's
nutrients, manufactures bile to help digest fats, produces many important proteins such as
blood clotting factors, and breaks down potentially toxic substances into harmless ones
that the body can use or excrete.
A number of conditions can cause damage to liver cells, resulting in an increase in ALT
levels. The test is most useful in detecting damage due to hepatitis and drugs or other
substances toxic to the liver. ALT, however, is not entirely specific for the liver, and mild
to moderately increased levels may also be seen in conditions affecting other parts of the
body.
21
The Test
How is it used?
The alanine aminotransferase (ALT) blood test is typically used to detect liver injury. It is
often ordered in conjunction with aspartate aminotransferase (AST) or as part of a liver
panel to screen for and/or help diagnose liver disease. AST and ALT are considered to be
two of the most important tests to detect liver injury, although ALT is more specific than
AST. Sometimes AST is compared directly to ALT and an AST/ALT ratio is calculated.
This ratio may be used to distinguish between different causes of liver damage.
ALT values are often compared to the results of other tests such as alkaline phosphatase
(ALP), total protein, and bilirubin to help determine which form of liver disease is present.
ALT is often used to monitor the treatment of persons who have liver disease, to see if the
treatment is working, and may be ordered either by itself or along with other tests for this
purpose.
When is it ordered?
A doctor usually orders an ALT test (and several others) to evaluate a person who has
symptoms of a liver disorder. Some of these symptoms include:
• Weakness, fatigue
• Loss of appetite
• Nausea, vomiting
• Abdominal swelling and/or pain
• Jaundice
• Dark urine, light colored stool
• Itching (pruritus)
ALT may also be ordered, either by itself or with other tests, for people who are at an
increased risk for liver disease. Some examples include:
• Persons who have a history of known or possible exposure to hepatitis viruses
• Those who are heavy drinkers
• Individuals whose families have a history of liver disease
• Persons who take drugs that might occasionally damage the liver
• Persons who are overweight and/or have diabetes
In persons with mild symptoms, such as fatigue or loss of energy, ALT may be tested to
make sure they do not have chronic liver disease.
When ALT is used to monitor the treatment of persons who have liver disease, it may be
ordered on a regular basis during the course of treatment to determine whether the therapy
is effective.
Normally, levels of ALT in the blood are low.
Very high levels of ALT (more than 10 times the highest normal level) are usually due to
acute hepatitis, often due to a virus infection. In acute hepatitis, ALT levels usually stay
high for about 1–2 months but can take as long as 3–6 months to return to normal. Levels
of ALT may also be markedly elevated as a result of exposure to drugs or other substances
that are toxic to the liver as well as in conditions that cause decreased blood flow
(ischemia) to the liver.
ALT levels are usually not as high in chronic hepatitis, often less than 4 times the highest
normal level. In this case, ALT levels often vary between normal and slightly increased, so
22
doctors typically will order the test frequently to see if there is a pattern. Other causes of
moderate increases in ALT include obstruction of bile ducts, cirrhosis (usually the result of
chronic hepatitis or bile duct obstruction), and with tumors in the liver.
In most types of liver diseases, the ALT level is higher than AST, and the AST/ALT ratio
will be low. There are a few exceptions. The AST/ALT ratio is usually increased in
alcoholic hepatitis, cirrhosis, and with muscle injury.
ALT is often performed together with a test for AST or as part of a liver panel. For more
about ALT results in relation to other liver tests, see the Liver Panel article.
A shot or injection of medicine into the muscle tissue, or strenuous exercise, may increase
ALT levels.
Many drugs may raise ALT levels by causing liver damage in a very small percentage of
patients taking the drug. This is true of both prescription drugs and some "natural" health
products. Be sure to tell your doctor about all the drugs and health supplements you are
taking. Eating too much fast food can also cause mild increases in ALT by causing liver
damage; this typically will return to normal when a normal diet is resumed.
Common Questions
1. What conditions other than liver problems can cause increased ALT?
ALT is more specific for the liver than AST and so is much less affected by conditions
affecting other parts of the body. Nevertheless, injury to organs other than the liver, such
as the heart and skeletal muscle, can cause slight elevations of ALT. For example, small
increases may be seen with acute pancreatitis and heart attacks.
2. What other tests may be performed to help determine the cause of liver damage?
After a thorough physical exam and evaluation of a person's medical history, there are
several other tests that may be performed as follow up depending on what is suspected to
be the cause of liver damage. Some of these include:
• Tests for hepatitis A, B, and C
• Testing for exposure to drugs and other substances toxic to the liver (Drugs of
Abuse Testing and Emergency of Overdose Drug Testing)
• Ethanol level
• Copper and ceruloplasmin for Wilson's disease
• Iron tests and genetic tests for hereditary hemochromatosis
• A liver biopsy
AST
Also known as: Serum glutamic-oxaloacetic transaminase; SGOT; Aspartate
transaminase; AST/ALT ratio
Formal name: Aspartate aminotransferase
23
Related tests: ALT; ALP; GGT; Bilirubin; Liver panel; Albumin, Total Protein
Why Get Tested?
To detect liver damage and/or to help diagnose liver disease
When to Get Tested?
When your doctor thinks that you have symptoms of a liver disorder
Sample Required?
None
Aspartate aminotransferase (AST) is an enzyme found in cells throughout the body but
mostly in the heart and liver, and to a lesser extent in the kidneys and muscles. In healthy
individuals, levels of AST in the blood are low. When liver or muscle cells are injured,
they release AST into the blood. This makes AST a useful test for detecting liver damage.
The liver is a vital organ located in the upper right-hand side of the abdominal area. It is
involved in many important functions in the body. The liver helps to process the body's
nutrients, manufactures bile to help digest fats, produces many important proteins such as
blood clotting factors, and breaks down potentially toxic substances into harmless ones
that the body can use or excrete.
A number of conditions can cause injury to liver cells and may cause increases in AST
levels. The test is most useful in detecting liver damage due to hepatitis, drugs toxic to the
liver, cirrhosis, and alcoholism. AST, however, it is not specific for the liver and may be
increased in conditions affecting other parts of the body.
The Test
How is it used?
The blood test for aspartate aminotransferase (AST) is usually used to detect liver damage.
It is often ordered in conjunction with another liver enzyme, alanine aminotransferase
(ALT), or as part of a liver panel to screen for and/or help diagnose liver disorders. AST
and ALT are considered to be two of the most important tests to detect liver injury,
although ALT is more specific than AST. Sometimes AST is compared directly to ALT
and an AST/ALT ratio is calculated. This ratio may be used to distinguish between
different causes of liver damage.
AST levels are often compared with results of other tests, such as alkaline phosphatase
(ALP), total protein, and bilirubin to help determine which form of liver disease is present.
AST is often measured to monitor treatment of persons with liver disease and may be
ordered either by itself or along with other tests for this purpose.
Sometimes AST may be used to monitor people who are taking medications that are
potentially toxic to the liver. If AST levels increase, then the person may be switched to
another medication.
When is it ordered?
An AST test is ordered along with several other tests to evaluate a person who has signs
and symptoms of a liver disorder. Some of these symptoms include:
• Weakness, fatigue
24
• Abdominal swelling and/or pain
• Jaundice
• Dark urine, light colored stool
• Itching (pruritus)
AST may also be ordered, either by itself or with other tests, for people who are at an
increased risk for liver disease. Some examples include:
• Persons who might have been exposed to hepatitis viruses
• Those who are heavy drinkers
• Persons who have a history of liver disease in their family
• Persons taking drugs that can occasionally damage the liver
• Persons who are overweight and/or have diabetes
Persons who have mild symptoms, such as fatigue, may be tested for ALT to make sure
they do not have chronic liver disease.
When AST is used to monitor treatment of persons with liver disease, it may be ordered on
a regular basis during the course of treatment to determine whether the therapy is
effective.
Normally, levels of AST in the blood are low.
Very high levels of AST (more than 10 times the highest normal level) are usually due to
acute hepatitis, often due to a virus infection. In acute hepatitis, AST levels usually stay
high for about 1–2 months but can take as long as 3–6 months to return to normal. Levels
of AST may also be markedly elevated as a result of exposure to drugs or other substances
that are toxic to the liver as well as in conditions that cause decreased blood flow
(ischemia) to the liver.
In chronic hepatitis, AST levels are usually not as high, often less than 4 times the highest
normal level. In chronic hepatitis, AST often varies between normal and slightly
increased, so doctors typically will order the test frequently to determine the pattern. Such
moderate increases may also be seen in certain diseases of the liver, especially when the
bile ducts are blocked, or with cirrhosis and certain cancers of the liver. AST is may also
increased after heart attacks and with muscle injury, usually to a much greater degree than
is ALT.
In most types of liver disease, the ALT level is higher than AST, and the AST/ALT ratio
will be low. There are a few exceptions. The AST/ALT ratio is usually increased in
alcoholic hepatitis, cirrhosis, and in the first day or two of acute hepatitis or injury from
bile duct obstruction.
AST is often performed together with the ALT test or as part of a liver panel. For more
about AST results in relation to other liver tests, see the Liver Panel article.
Pregnancy may decrease AST levels.
A shot or injection of medicine into muscle tissue, or even strenuous exercise, may
increase AST levels.
25
In rare instances, some drugs can damage the liver or muscle, increasing AST levels. This
is true of both prescription drugs and some "natural" health products. Be sure to tell your
doctor about all the drugs and health supplements you are taking.
Common Questions
1. What conditions other than liver problems can cause increased AST?
Conditions that affect other organs, such as the heart and skeletal muscle, can cause
elevations of AST. Mild to moderate increases may be seen with vigorous excercise and
muscle injury or in conditions such as acute pancreatitis and heart attacks.
2. What other tests may be used to help determine the cause of liver damage?
After a thorough physical exam and evaluation of a person's medical history, there are
several other tests that may be performed as follow up depending on what is suspected to
be the cause of liver damage. Some of these include:
• Tests for hepatitis A, B, and C
• Testing for exposure to drugs and other substances toxic to the liver (Drugs of
Abuse Testing and Emergency of Overdose Drug Testing)
• Ethanol level
• Copper and ceruloplasmin for Wilson's disease
• Iron tests and genetic tests for hereditary hemochromatosis
• A liver biopsy
Creatinine
Also known as: Creat; Cre; Blood creatinine; Serum creatinine; Urine creatinine
Formal name: Creatinine
Related tests: BUN; BUN/creatinine ratio; eGFR; Creatinine clearance; CMP; BMP;
Urinalysis; Urine protein to creatinine ratio; Microalbumin
Why Get Tested?
To determine if your kidneys are functioning normally and to monitor treatment for kidney
disease
When to Get Tested?
Routinely as part of a comprehensive or basic metabolic panel; if your doctor suspects that
you are suffering from kidney dysfunction or if you are acutely or chronically ill with a
condition that may affect your kidneys and/or be worsened by kidney dysfunction; at
intervals to monitor treatment for kidney disease or kidney function while on certain
medications
Sample Required?
A blood sample drawn from a vein in the arm and/or a 24-hour urine sample
None
This test measures the amount of creatinine in your blood and/or urine. Creatinine is a
waste product produced in your muscles from the breakdown of a compound called
26
creatine. Creatine is part of the cycle that produces energy needed to contract your
muscles. Both creatine and creatinine are produced by the body at a relatively constant
rate. Almost all creatinine is excreted by the kidneys, so blood levels are a good measure
of how well your kidneys are working. The quantity produced depends on the size of the
person and their muscle mass. For this reason, creatinine concentrations will be slightly
higher in men than in women and children.
Results from a blood creatinine test and a 24-hour urine creatinine test may be used to
calculate creatinine clearance.
How is the sample collected for testing?
A blood sample is drawn from a vein in the arm. You may be asked to collect a complete
24-hour urine sample in addition to having your blood drawn. Your doctor or the
laboratory will give you a large container and instructions for properly collecting this
sample. Typically, you start collecting urine after you wake up in the morning and empty
your bladder. This morning urine sample is not collected, but the time is recorded and used
as the start time for the 24-hour collection. The next time you empty your bladder, you
save this urine and all of the urine produced until the same time the following day.
The Test
How is it used?
The creatinine blood test is used along with a BUN (blood urea nitrogen) test to assess
kidney function. Both are frequently ordered as part of a basic or comprehensive metabolic
panel (BMP or CMP), groups of tests that are performed to evaluate the function of the
body’s major organs. BMP or CMP tests are used to screen healthy people during routine
physical exams and to help evaluate acutely or chronically ill patients in the emergency
room and/or hospital. If the creatinine and BUN tests are found to be abnormal or if you
have an underlying disease, such as diabetes, that is known to affect the kidneys, then
these two tests may be used to monitor the progress of kidney dysfunction and the
effectiveness of treatment. Blood creatinine and BUN tests may also be ordered to
evaluate kidney function prior to some procedures, such as a CT (computed tomography)
scan, that may require the use of drugs that can damage the kidneys.
A combination of blood and urine creatinine levels may be used to calculate a creatinine
clearance. This test measures how effectively your kidneys are filtering small molecules
like creatinine out of your blood.
Urine creatinine may also be used with a variety of other urine tests as a correction factor.
Since it is produced and removed at a relatively constant rate, the amount of urine
creatinine can be compared to the amount of another substance being measured. Examples
of this are when creatinine is measured with protein to calculate a urine protein/creatinine
ratio (UP/CR) and when it is measured with microalbumin to calculate
microalbumin/creatinine ratio (also known as albumin/creatinine ratio, ACR). These tests
are used to evaluate kidney function as well as to detect other urinary tract disorders.
Serum creatinine measurements (along with your age, weight, and gender) also are used to
calculate the estimated glomerular filtration rate (eGFR), which is used as a screening test
to look for evidence of kidney damage.
When is it ordered?
27
Creatinine may be ordered routinely as part of a comprehensive or basic metabolic panel,
during a health examination. It may be ordered when you have non-specific health
complaints, when you are acutely ill, and/or when your doctor suspects your kidneys are
not working properly. Some signs and symptoms of kidney dysfunction include:
• Fatigue, lack of concentration, poor appetite, or trouble sleeping
• Swelling or puffiness, particularly around the eyes or in the face, wrists, abdomen,
thighs or ankles
• Urine that is foamy, bloody, or coffee-colored
• A decrease in the amount of urine
• Problems urinating, such as a burning feeling or abnormal discharge during
urination, or a change in the frequency of urination, especially at night
• Mid-back pain (flank), below the ribs, near where the kidneys are located
• High blood pressure
The creatinine blood test may be ordered, along with BUN test and microalbumin, at
regular intervals when you have a known kidney disorder or have a disease that may affect
kidney function or be exacerbated by dysfunction. Both BUN and creatinine may be
ordered when a CT scan is planned, prior to and during certain drug therapies, and before
and after dialysis to monitor the effectiveness of treatments.
Increased creatinine levels in the blood suggest diseases or conditions that affect kidney
function. These can include:
• Damage to or swelling of blood vessels in the kidneys (glomerulonephritis) caused
by, for example, infection or autoimmune diseases
• Bacterial infection of the kidneys (pyelonephritis)
• Death of cells in the kidneys’ small tubes (acute tubular necrosis) caused, for
example, by drugs or toxins
• Prostate disease, kidney stone, or other causes of urinary tract obstruction
• Reduced blood flow to the kidney due to shock, dehydration, congestive heart
failure, atherosclerosis, or complications of diabetes
Creatinine blood levels can also increase temporarily as a result of muscle injury and are
generally slightly lower during pregnancy.
Low blood levels of creatinine are not common, but they are also not usually a cause for
concern. They can be seen with conditions that result in decreased muscle mass.
Levels of 24-hour urine creatinine are evaluated with blood levels as part of a creatinine
clearance test.
Random urine creatinine levels have no standard reference ranges. They are usually used
with other tests to reference levels of other substances measured in the urine. Some
examples include the microalbumin test and urine protein test.
NOTE: The result of your blood creatinine test is measured by your doctor against a
reference range for the test to determine whether the result is “normal” (it is within the
range of numbers), high (it is above the high end of the range), or low (it is below the low
end of the range). Because there can be many variables that affect the determination of
the reference range, the reference range for this test is specific to the lab where your test
sample is analyzed. For this reason, the lab is required to report your results with an
28
accompanying reference range. Typically, your doctor will have sufficient familiarity with
the lab and your medical history to interpret the results appropriately
While there is no such thing as a “standard” reference range for blood creatinine, most
labs will report a similar, though maybe not exactly the same, set of numbers as that
included in medical textbooks or found elsewhere online. For this reason, we recommend
that you talk with your doctor about your lab results. For general guidance only, we are
providing the reference range for this test below from the classic medical text, Tietz
Textbook of Clinical Chemistry and Molecular Diagnostics.
For more information on reference ranges, please read Reference Ranges and What They
Mean.
Drugs such as aminoglycosides (vancomycin, gentamicin) can cause kidney damage and
so creatinine is monitored. Other drugs, such as cephalosprins (cefoxitin), may increase
creatinine concentration without reflecting kidney damage.
Common Questions
1. Will exercise affect my creatinine levels?
In general, moderate exercise will not affect your creatinine levels. As you continue to
exercise and build muscle mass, your creatinine levels may increase slightly but not to
abnormal levels.
2. How does diet affect creatinine levels?
In general, creatinine levels will not vary with a normal diet. Creatinine levels may be
10%-30% higher in people who eat a diet that is very high in meat.
3. What is creatine? If I take creatine, will my creatinine levels go up?
Creatine is a compound that is made primarily in the liver and then transported to your
muscles, where it is used as an energy source for muscle activity. Once in the muscle,
some of the creatine is spontaneously converted to creatinine. The amount of both creatine
and creatinine depend on muscle mass, so men usually have higher levels than women.
Creatine is now available as a dietary supplement. If you take creatine, your creatinine
levels may be higher than when you do not take the supplement. You should tell your
doctor about all of the dietary supplements you are taking to help her evaluate your lab
results.
4. Do creatinine levels change with age?
Creatinine levels relate to both muscle mass and to kidney function. As you age, your
muscle mass decreases but your kidneys tend to function less effectively. The net result is
not much change in creatinine levels in the blood as you get older.
5. What is a BUN/Creatinine ratio?
Occasionally, a doctor will look at the ratio between a person’s BUN and blood creatinine
to help them determine what is causing these concentrations to be higher than normal. The
ratio of BUN to creatinine is usually between 10:1 and 20:1. An increased ratio may be
due to a condition that causes a decrease in the flow of blood to the kidneys, such as
congestive heart failure or dehydration. It may also be seen with increased protein, from
gastrointestinal bleeding, or increased protein in the diet. The ratio may be decreased with
liver disease (due to decrease in the formation of urea) and malnutrition.
29
BUN
Also known as: Urea nitrogen; Urea
Formal name: Blood Urea Nitrogen
Related tests: Creatinine; Creatinine Clearance; eGFR; CMP; BMP; Urinalysis;
Microalbumin
Why Get Tested?
To evaluate kidney function or monitor the effectiveness of dialysis and other treatments
related to kidney disease or damage
When to Get Tested?
As part of a routine comprehensive or basic metabolic panel or when you are acutely or
chronically ill with a condition that may cause or be worsened by kidney dysfunction
Sample Required?
None
This test measures the amount of urea nitrogen in the blood. Nitrogen, in the form of
ammonia, is produced in the liver when protein is broken into its component parts (amino
acids) and metabolized. The nitrogen combines with other molecules in the liver to form
the waste product urea. The urea is then released into the bloodstream and carried to the
kidneys, where it is filtered out of the blood and excreted in the urine. Since this is an
ongoing process, there is usually a small but stable amount of urea nitrogen in the blood.
Most diseases or conditions that affect the kidneys or liver have the potential to affect the
amount of urea present in the blood. If increased amounts of urea are produced by the liver
or decreased amounts are excreted by the kidneys, then urea concentrations will rise. If
significant liver damage or disease inhibits the production of urea, then BUN
concentrations may fall.
The Test
How is it used?
The BUN test is primarily used, along with the creatinine test, to evaluate kidney function
in a wide range of circumstances, to help diagnose kidney disease, and to monitor patients
with acute or chronic kidney dysfunction or failure. It also may be used to evaluate a
person’s general health status when ordered as part of a basic metabolic panel (BMP) or
comprehensive metabolic panel (CMP).
When is it ordered?
BUN is part of both the BMP and CMP, groups of tests that are widely used:
• When someone has non-specific complaints
• As part of a routine testing panel
• To check how the kidneys are functioning before starting to take certain drug
therapies
30
• When an acutely ill person comes to the emergency room and/or is admitted to the
hospital
• During a hospital stay
BUN is often ordered with creatinine when kidney problems are suspected. Some signs
and symptoms of kidney dysfunction include:
• Fatigue, lack of concentration, poor appetite, or trouble sleeping
• Swelling or puffiness (edema), particularly around the eyes or in the face, wrists,
abdomen, thighs, or ankles
• Urine that is foamy, bloody, or coffee-colored
• A decrease in the amount of urine
• Problems urinating, such as a burning feeling or abnormal discharge during
urination, or a change in the frequency of urination, especially at night
• Mid-back pain (flank), below the ribs, near where the kidneys are located
BUN also may be ordered:
• At regular intervals to monitor kidney function in patients with chronic diseases or
conditions such as diabetes, congestive heart failure, and myocardial infarction
(heart attack)
• At regular intervals to monitor kidney function and treatment in patients with
known kidney disease
• Prior to and during certain drug treatments to monitor kidney function
• At regular intervals to monitor the effectiveness of dialysis.
Increased BUN levels suggest impaired kidney function. This may be due to acute or
chronic kidney disease, damage, or failure. It may also be due to a condition that results in
decreased blood flow to the kidneys, such as congestive heart failure, shock, stress, recent
heart attack, or severe burns, to conditions that cause obstruction of urine flow, or to
dehydration.
BUN concentrations may be elevated when there is excessive protein breakdown
(catabolism), significantly increased protein in the diet, or gastrointestinal bleeding
(because of the proteins present in the blood).
Low BUN levels are not common and are not usually a cause for concern. They may be
seen in severe liver disease, malnutrition, and sometimes when a patient is overhydrated
(too much fluid volume), but the BUN test is not usually used to diagnose or monitor these
conditions.
Both decreased and increased BUN concentrations may be seen during a normal
pregnancy.
If one kidney is fully functional, BUN concentrations may be normal even when
significant dysfunction is present in the other kidney.
NOTE: The result of your BUN test is measured by your doctor against a reference range
for the test to determine whether the result is “normal” (it is within the range of
numbers), high (it is above the high end of the range), or low (it is below the low end of
the range). Because there can be many variables that affect the determination of the
reference range, the reference range for this test is specific to the lab where your test
31
While there is no such thing as a “standard” reference range for BUN, most labs will
report a similar, though maybe not exactly the same, set of numbers as that included in
medical textbooks or found elsewhere online. For this reason, we recommend that you talk
with your doctor about your lab results. For general guidance only, we are providing the
reference range for this test below from the classic medical text, Tietz Textbook of Clinical
Chemistry and Molecular Diagnostics.
Mean.
BUN levels can increase with the amount of protein in your diet. High-protein diets may
cause abnormally high BUN levels while very low-protein diets can cause an abnormally
low BUN.
Common Questions
1. What other tests are used with BUN to check how my kidneys are functioning?
BUN and creatinine are the primary tests used to check how well the kidneys are able to
filter waste products from your blood. Your doctor may also order electrolyte tests such as
sodium and potassium, or calcium to help understand how your kidneys are functioning.
2. How does BUN change with age?
BUN levels increase with age. BUN levels in very young babies are about 2/3 of the
levels found in healthy young adults, while levels in adults over 60 years of age are
slightly higher than younger adults. Levels are also slightly higher in men than women.
3. What is a BUN/Creatinine ratio?
Occasionally, a doctor will look at the ratio between a person’s BUN and blood creatinine
to help them determine what is causing these concentrations to be higher than normal. The
ratio of BUN to creatinine is usually between 10:1 and 20:1. An increased ratio may be
due to a condition that causes a decrease in the flow of blood to the kidneys, such as
congestive heart failure or dehydration. It may also be seen with increased protein, from
gastrointestinal bleeding, or increased protein in the diet. The ratio may be decreased with
liver disease (due to decrease in the formation of urea) and malnutrition.
Bilirubin
Also known as: Total bilirubin; TBIL; Neonatal bilirubin; Direct bilirubin; Conjugated
bilirubin; Indirect bilirubin; Unconjugated bilirubin
Formal name: Bilirubin
Related tests: Liver panel; Gamma-glutamyl transferase; Alkaline phosphatase; Aspartate
aminotransferase; Alanine aminotransferase; Hepatitis A; Hepatitis B; Hepatitis C
Why Get Tested?
To screen for or monitor liver disorders
When to Get Tested?
If your doctor thinks you have signs or symptoms of liver damage, liver disease, bile duct
blockage, hemolytic anemia, or a liver-related metabolic problem
32
Sample Required?
In adults, a blood sample from a vein in the arm; in newborns, a blood sample from a
heelstick; non-invasive technology is available in some health care facilities that will
measure bilirubin by using an instrument placed on the skin (transcutaneous bilirubin
meter)
None
Bilirubin is an orange-yellow pigment found in bile. Red blood cells (RBCs) normally
degrade after 120 days in the circulation. At this time, a component of the RBCs,
hemoglobin (the red-colored pigment of red blood cells that carries oxygen to tissues),
breaks down into unconjugated bilirubin. Approximately 250 to 350 mg of bilirubin is
produced daily in a normal, healthy adult, of which 85% is derived from damaged or old
red cells that have died, with the remaining amount from the bone marrow or liver.
Unconjugated bilirubin is carried to the liver, where sugars are attached to it to make it
water soluble, producing conjugated bilirubin. This conjugated bilirubin is passed to the
bile by the liver and is further broken down by bacteria in the small intestines and
eventually excreted in the feces. The breakdown products of bilirubin give feces its
characteristic brown color. If bilirubin levels increase in the blood, the appearance of
jaundice becomes more evident. Normally, almost all bilirubin in the blood is
unconjugated.
The Test
How is it used?
When bilirubin levels are high, a condition called jaundice occurs, and further testing is
needed to determine the cause. Too much bilirubin may mean that too much is being
produced (usually due to increased hemolysis) or that the liver is incapable of adequately
removing bilirubin in a timely manner due to blockage of bile ducts, liver diseases such as
cirrhosis, acute hepatitis, or inherited problems with bilirubin processing.
It is not uncommon to see high bilirubin levels in newborns, typically 1 to 3 days old. This
is sometimes called physiologic jaundice of the newborn. Within the first 24 hours of life,
up to 50% of full-term newborns, and an even greater percentage of pre-term babies, may
have a high bilirubin level. After birth, newborns begin breaking down the excess red
blood cells (RBCs) they are born with and, since the newborn’s liver is not fully mature, it
is unable to process the extra bilirubin, causing the infant's bilirubin levels to rise in the
blood and other body tissues. This situation usually resolves itself within a few days. In
other instances, newborns’ red blood cells may be being destroyed because of blood
incompatibilities between the baby and her mother, called hemolytic disease of the
newborn.
In adults or older children, bilirubin is measured to diagnose and/or monitor liver diseases,
such as cirrhosis, hepatitis, or gallstones. Patients with sickle cell disease or other causes
of hemolytic anemia may have episodes where excessive RBC destruction takes place,
increasing bilirubin levels.
When is it ordered?
33
A doctor usually orders a bilirubin test in conjunction with other laboratory tests (alkaline
phosphatase, aspartate aminotransferase, alanine aminotransferase) for a patient who
shows signs of abnormal liver function. A bilirubin level may be ordered when a patient:
• shows evidence of jaundice
• has a history of drinking excessive amounts of alcohol
• has suspected drug toxicity
• has been exposed to hepatitis viruses
Other symptoms that may be present include:
• dark, amber-colored urine
• nausea/vomiting
• abdominal pain and/or swelling
• fatigue and general malaise that often accompany chronic liver disease
Determining a bilirubin level in newborns with jaundice is considered standard medical
care.
Newborns: Excessive bilirubin damages developing brain cells in infants (kernicterus) and
may cause mental retardation, learning and developmental disabilities, hearing loss, or eye
movement problems. It is important that bilirubin in newborns does not get too high.
When the level of bilirubin is above a critical threshold, special treatments are initiated to
lower it. An excessive bilirubin level may result from the accelerated breakdown of red
blood cells due to a blood type incompatibility between the mother and her newborn (e.g.,
the mother is Rh-negative and has antibody to Rh-positive blood - the father is Rh-
positive, and the fetus inherits this trait from him; the mother’s antibody crosses the
placenta and causes the fetal Rh-positive red blood cells to hemolyze, resulting in
excessively elevated bilirubin levels with jaundice, anemia, and possible kernicterus.)
Adults and children: Bilirubin levels can be used to identify liver damage/disease or to
monitor the progression of jaundice. Increased total or unconjugated bilirubin may be a
result of hemolytic, sickle cell or pernicious anemias or a transfusion reaction. If
conjugated bilirubin is elevated, there may be some kind of blockage of the liver or bile
ducts, hepatitis, trauma to the liver, cirrhosis, a drug reaction, or long-term alcohol abuse.
Inherited disorders that cause abnormal bilirubin metabolism (Gilbert’s, Rotor’s, Dubin-
Johnson, Crigler-Najjar syndromes) may also cause increased levels.
Low levels of bilirubin are not generally a concern and are not monitored.
Although bilirubin may be toxic to brain development in newborns (up to the age of about
2–4 weeks), high bilirubin in older children and adults does not pose the same threat. In
older children and adults, the “blood-brain barrier” is more developed and prevents
bilirubin from crossing this barrier to the brain cells. Elevated bilirubin levels in children
or adults, however, strongly suggest a medical condition that must be evaluated and
treated.
Bilirubin is not normally present in the urine. However, conjugated bilirubin is water-
soluble and therefore may be excreted from the body in the urine when levels increase in
the body. Its presence in the urine usually indicates blockage of liver or bile ducts,
hepatitis or some other liver damage. The most common method for detecting urine
bilirubin is using the dipstick test that is part of a urinalysis.
34
Bilirubin levels tend to be slightly higher in males than females, while African Americans
show lower values. Strenuous exercise may also increase bilirubin levels.
Common Questions
1. Are some people more at genetic risk of abnormal bilirubin levels?
Several inherited chronic conditions include Gilbert’s syndrome, Dubin-Johnson
syndrome, Rotor’s syndrome, and Crigler-Najjar syndrome. Of these four syndromes,
Crigler-Najjar is the most serious and may result in death. The first three are usually mild,
chronic conditions that can be aggravated under certain conditions but in general cause no
significant health problems.
2. How do you treat abnormal bilirubin levels and/or jaundice?
Treatment depends on the cause of the jaundice. In newborns, phototherapy (special light
therapy), blood exchange transfusion in severe cases, and certain drugs may reduce the
bilirubin level. In Gilbert’s, Rotor’s, and Dubin-Johnson syndromes, no treatment is
usually necessary. Crigler-Najjar syndrome may respond to certain enzyme drug therapy
or may require a liver transplant. Jaundice caused by an obstruction often is resolved by
surgery to remove the blockage. Jaundice due to cirrhosis is often a result of long-term
viral hepatitis or alcohol abuse and may not respond well to any type of therapy. Anti-viral
medications, abstaining from alcohol, avoiding other potential liver toxins, and good
nutrition may improve the situation if the liver has not been damaged too badly.
3. Is there anything I can do to maintain healthy bilirubin levels?
While there is no one specific thing, it is clear that excessive and long- term alcohol
consumption can lead to cirrhosis and a permanently damaged liver. Avoiding alcohol and
over-use/long-term use of drugs and eating a proper diet may help to sustain a healthy
liver. Blockages due to duct stones, pancreatic cancer, or cysts may require surgery.
Potassium
Also known as: K
Formal name: Potassium
Related tests: Chloride, Sodium, Bicarbonate (or Total CO2), Electrolyte panel, BMP,
CMP, Aldosterone and Renin
Why Get Tested?
To determine whether your potassium concentration is within normal limits and to help
evaluate an electrolyte imbalance; to monitor chronic or acute hyperkalemia or
hypokalemia
When to Get Tested?
As part of a routine medical exam, when you have symptoms such as weakness and/or
cardiac arrhythmia, or when an electrolyte imbalance is suspected; at regular intervals
when you are taking a medication and/or have a disease or condition, such as high blood
pressure (hypertension) or kidney disease, that can affect your potassium level
Sample Required?
None
35
Potassium is an electrolyte, a positively charged molecule that works with other
electrolytes, such as sodium, chloride, and bicarbonate (total CO2) to help regulate the
amount of fluid in the body, stimulate muscle contraction, and maintain a stable acid-base
balance. Potassium is present in all body fluids, but most potassium is found within your
cells. Only about two percent is present in fluids outside the cells and in the liquid part of
the blood (called serum or plasma). Because the blood concentration of potassium is so
small, minor changes can have significant consequences. If potassium levels go too low or
too high, your health may be in considerable danger: you are at risk for developing shock,
respiratory failure, or heart rhythm disturbances. An abnormal concentration can alter the
function of neuromuscular tissue; for example, the heart muscle may lose its ability to
contract.
The Test
How is it used?
Potassium testing is frequently ordered, along with other electrolytes, as part of a routine
physical. It is used to detect concentrations that are too high (hyperkalemia) or too low
(hypokalemia). The most common cause of hyperkalemia is kidney disease, but many
drugs can decrease potassium excretion from the body and result in this condition.
Hypokalemia can occur if you have diarrhea and vomiting or if you are sweating
excessively. Potassium can be lost through your kidneys in urine; in rare cases, potassium
may be low because you are not getting enough in your diet.
Potassium concentrations may be ordered at regular intervals to monitor drugs that can
cause your kidneys to lose potassium, particularly diuretics, resulting in hypokalemia.
Monitoring may also be done if you have a condition or disease, such as acute or chronic
kidney failure, that can be associated with abnormal potassium levels.
When is it ordered?
Serum or plasma tests for potassium levels are routinely performed in most patients when
they are investigated for any type of serious illness. Also, because potassium is so
important to heart function, it is usually ordered (along with other electrolytes) during all
complete routine evaluations, especially in those who take diuretics or or blood pressure or
heart medications. Potassium is ordered when a doctor is diagnosing and evaluating high
blood pressure (hypertension) and kidney disease and when monitoring a patient receiving
dialysis, diuretic therapy, or intravenous therapy.
Increased potassium levels indicate hyperkalemia. Increased levels may also indicate the
following health conditions:
• acute or chronic kidney failure
• Addison's disease
• hypoaldosteronism (see Aldosterone)
• injury to tissue
• infection
• diabetes
36
• dehydration
• excessive dietary potassium intake (for example, fruits are particularly high in
potassium, so excessive intake of fruits or juices may contribute to high potassium)
• excessive intravenous potassium intake
Certain drugs can also cause hyperkalemia in a small percent of patients. Among them are
non-steroidal anti-inflammatory drugs (such as Advil, Motrin, and Nuprin); beta blockers
(such as propanolol and atenolol), angiotensin-converting enzyme inhibitors (such as
captopril, enalapril, and lisinopril), and potassium-sparing diuretics (such as triamterene,
amiloride, and spironolactone).
Decreased levels of potassium indicate hypokalemia. Decreased levels may occur in a
number of conditions, particularly:
• dehydration
• vomiting
• diarrhea
• Hyperaldosteronism (see Aldosterone)
• deficient potassium intake (rare)
• as a complication of acetaminophen overdose
In diabetes, your potassium may fall after you take insulin, particularly if your diabetes
had been out of control for a while. Low potassium is commonly due to "water pills"
(diuretics); if you are taking these, your doctor will check your potassium level regularly.
Additionally, certain drugs such as corticosteroids, beta-adrenergic agonists such as
isoproterenol, alpha-adrenergic antagonists such as clonidine, antibiotics such as
gentamicin and carbenicillin, and the antifungal agent amphotericin B can cause loss of
potassium.
NOTE: The result of your potassium test is measured by your doctor against a reference
range for the test to determine whether the result is “normal” (it is within the range of
While there is no such thing as a “standard” reference range for potassium, most labs
will report a similar, though maybe not exactly the same, set of numbers as that included
in medical textbooks or found elsewhere online. For this reason, we recommend that you
talk with your doctor about your lab results. For general guidance only, we are providing
the reference range for this test below from the classic medical text, Tietz Textbook of
Clinical Chemistry and Molecular Diagnostics.
Mean.
Physicians question elevated potassium results when the numbers do not fit the patient's
clinical condition. Potassium levels can be falsely elevated by the following specimen-
collection or -processing errors:
• Clenching and relaxing your fist a lot while your blood is drawn.
37
• Collecting the specimens without regard for the proper order of draw of the tubes;
that is, drawing a tube that has an anticoagulant containing potassium prior to a non-
anticoagulated tube. This results in specimen contamination of the non-
anticoagulated tube with potassium.
• Delayed handling or processing of the specimen. The red cells and serum or plasma
need to be separated within the appropriate clot to centrifugation time. This also
reduces error if the specimen has to be transported from your doctor's office to a
laboratory.
• Improper centrifugation
• Any action that can cause the red cells to break apart (hemolyze) and release more
potassium into the specimen. This may include using a large diameter needle
(causes the blood to enter the evacuate collection tube with too much force),
inverting the tube too vigorously, drawing the blood through a small needle, and
using a syringe with excessive suction applied to the plunger.
• Crying and hyperventilation can either increase or decrease the plasma potassium
level.
If there are any questions as to how your blood was collected, your doctor may request
that the test be repeated to verify results.
Common Questions
1. What are some good dietary sources of potassium?
Low levels of potassium can be a result of increased urinary loss due to certain heart
medications that lower sodium levels and prevent water retention. To make up for this loss
of potassium, doctors often suggest eating more foods high in potassium. A number of
fruits and vegetables (bananas, cantaloupe, grapefruit, oranges, tomatoes, honeydew
melons, potatoes) and meats are good sources of potassium.
2. Is there an over-the-counter test I can use to check my potassium levels?
No. Electrolyte tests are performed by trained laboratorians using highly sensitive
instruments.
Sodium
Also known as: Na
Formal name: Sodium
Related tests: Chloride, Bicarbonate (or total CO2), Potassium, Electrolyte panel,
Osmolality, BMP, CMP, Aldosterone, ADH
Why Get Tested?
38
To determine whether your sodium concentration is within normal limits and to help
evaluate electrolyte balance and kidney function; to monitor chronic or acute
hypernatremia or hyponatremia
When to Get Tested?
If you are experiencing dehydration or edema; also to monitor certain chronic conditions,
like high or low blood pressure
Sample Required?
A blood sample drawn from a vein in the arm or, in some cases, a urine sample
None
This test measures the level of sodium in the blood. Sodium is a mineral that is vital to
normal body processes, which include nerve and muscle functioning. Too much sodium,
however, can increase the chances of high blood pressure. Sodium is a positively charged
molecule that works with other electrolytes, such as potassium, chloride, and bicarbonate
(or total CO2), to help your cells function normally and help regulate the amount of fluid
in the body. For example, you lose electrolytes when you sweat, and you must replace
them. Sodium is present in all body fluids but is found in the highest concentration in the
blood and in the fluid outside of the body’s cells. This extracellular sodium, as well as all
body water, is regulated by the kidney.
We get sodium in our diet, from table salt (sodium chloride or NaCl), and to some degree
from most of the foods that we eat. Most people have an adequate intake of sodium. The
body uses what it requires and the kidneys excrete the rest in the urine to maintain sodium
concentration within a very narrow range. It does this by:
 producing hormones that can increase (natriuretic peptides) or decrease (aldosterone)
sodium losses in urine,
 producing a hormone that prevents water losses (antidiuretic hormone, ADH), and
 controlling thirst. (Even a 1% increase in blood sodium will make you thirsty and
cause you to drink water, returning your sodium level to normal.)
Abnormal blood sodium is usually due to some problem with one of these control systems.
When the level of sodium in the blood changes, the water content in your body also
changes. These changes can be associated with dehydration or edema, especially in the
legs.
The Test
How is it used?
Blood sodium testing is used to detect hyponatremia or hypernatremia associated with
dehydration, edema, and a variety of diseases. Your doctor may order this test, along with
other electrolytes, to screen for an electrolyte imbalance. It may be ordered to determine if
a disease or condition involving the brain, lungs, liver, heart, kidney, thyroid, or adrenal
glands is causing or being exacerbated by a sodium deficiency or excess. In patients with a
39
known electrolyte imbalance, a blood sodium test may be ordered at regular intervals to
monitor the effectiveness of treatment. It may also be ordered to monitor patients taking
medications that can affect sodium levels, such as diuretics.
Urine sodium levels are typically tested in patients who have abnormal blood sodium
levels to help determine whether an imbalance is from, for example, taking in too much
sodium or losing too much sodium. Urine sodium testing is also used to see if a person
with high blood pressure is eating too much salt. It is often used in persons with abnormal
kidney tests to help the doctor determine the cause of kidney damage, which can help
guide treatment.
When is it ordered?
This test is a part of the routine lab evaluation of most patients. It is one of the blood
electrolytes, which are often ordered as a group. It is also included in the basic metabolic
panel, widely used when someone has non-specific health complaints, and in monitoring
treatment involving IV fluids or when there is a possibility of developing dehydration.
Electrolyte panels and basic metabolic panels are also commonly used to monitor
treatment of certain problems, including high blood pressure, heart failure, and liver and
kidney disease.
A blood sodium test may be ordered when a patient has symptoms of hyponatremia, such
as weakness, confusion, and lethargy, or symptoms of hypernatremia such as thirst,
decreased urinary output, muscle twitching, and/or agitation.
A low level of blood sodium means you have hyponatremia, which is usually due to too
much sodium loss, too much water intake or retention, or to fluid accumulation in the body
(edema). If sodium falls quickly, you may feel weak and fatigued; in severe cases, you
may experience confusion or even fall into a coma. When sodium falls slowly, however,
there may be no symptoms. That is why sodium levels are often checked even if you don’t
have any symptoms.
Hyponatremia is rarely due to decreased sodium intake (deficient dietary intake or
deficient sodium in IV fluids). Most commonly, it is due to sodium loss (Addison's
disease, diarrhea, excessive sweating, diuretic administration, or kidney disease). In some
cases, it is due to increased water (drinking too much water, heart failure, cirrhosis, kidney
diseases that cause protein loss [nephrotic syndrome]). In a number of diseases
(particularly those involving the brain and the lungs, many kinds of cancer, and with some
drugs), your body makes too much anti-diuretic hormone (ADH), causing you to keep too
much water in your body.
A high blood sodium level means you have hypernatremia and is almost always due to
dehydration without enough water intake. Symptoms include dry mucous membranes,
thirst, agitation, restlessness, acting irrationally, and coma or convulsions if levels rise
extremely high. In rare cases, hypernatremia may be due to increased salt intake without
enough water, Cushing syndrome, or a condition caused by too little ADH, called diabetes
insipidus.
Sodium urine concentrations must be evaluated in association with blood levels.
Concentrations may mirror blood levels or be the opposite. The body normally excretes
excess sodium, so the concentration in the urine may be elevated because it is elevated in
the blood. It may also be elevated in the urine when the body is losing too much sodium.
40
In this case, the blood level would be normal to low. If blood sodium levels are low due to
insufficient intake, then urine concentrations will also be low.
• Decreased urinary sodium levels may indicate dehydration, congestive heart failure,
liver disease, or nephrotic syndrome.
• Increased urinary sodium levels may indicate diuretic use or Addison's disease.
Sodium levels are often evaluated in relation to other electrolytes and can be used to
calculate anion gap in order to identify the cause of acidosis.
NOTE: The result of your sodium test is measured by your doctor against a reference
range for the test to determine whether the result is “normal” (it is within the range of
While there is no such thing as a “standard” reference range for sodium, most labs will
report a similar, though maybe not exactly the same, set of numbers as that included in
medical textbooks or found elsewhere online. For this reason, we recommend that you talk
with your doctor about your lab results. For general guidance only, we are providing the
reference range for this test below from the classic medical text, Tietz Textbook of Clinical
Chemistry and Molecular Diagnostics.
Mean.
Certain drugs such as anabolic steroids, corticosteroids, laxatives, cough medicines, and
oral contraceptives may cause increased levels of sodium. Other drugs such as diuretics,
carbamazepine, and tricyclic antidepressants may cause decreased levels of sodium.
Common Questions
1. What is the recommended dietary salt intake?
The Food and Nutrition Board recommends a sodium intake of less than 2400 mg per day
for adults. People normally obtain adequate amounts of sodium in their daily diet, but it is
important not to exceed this recommended maximum amount.
Common dietary sources of sodium are often processed food to which salt is added during
preparation, such as cheeses, soups, pickles, and pretzels. Additionally, other processed,
commercially prepared, or restaurant foods are generally high in sodium.
For people who are sodium sensitive or have hypertension, reducing sodium intake can
lead to markedly beneficial health effects. But even if you don’t have high blood pressure,
limiting sodium as part of a healthy diet may decrease your risk of developing blood
pressure problems and heart disease.
Your taste for salt is both acquired and reversible. As you use less salt, your preference for
it will lessen. The Mayo Clinic Women’s HealthSource offers ways to control sodium
intake.
2. Is anyone at particular risk for low or high sodium levels?
41
Yes. People who have diarrhea, profuse sweating, burns, vomiting, Addison’s disease,
kidney disease, or congestive heart failure may have low sodium levels. People with
dehydration, diuretic use, Cushing’s syndrome, cystic fibrosis, neurological disorders,
hypothyroidism, or renal failure may have high sodium levels
42
Hepatitis A
Also known as: HAV-Ab IgM; HAV-Ab IgG; HAV-Ab total
Formal name: Viral Hepatitis A Antibody
Related tests: Hepatitis B; Hepatitis C; Liver Panel; AST; ALT; ALP; Bilirubin
Why Get Tested?
To diagnose an infection with hepatitis A virus (HAV) or to evaluate the need for or
response to the hepatitis A vaccine
When to Get Tested?
If you have symptoms of an infection with and/or have been exposed to HAV; if you have
chronic liver disease; or if you have received the HAV vaccine
Sample Required?
None
Hepatitis A is a highly contagious liver infection caused by the hepatitis A virus (HAV). It
is one of several various causes of hepatitis, a condition characterized by inflammation and
enlargement of the liver. Hepatitis A is one of five "hepatitis viruses" identified so far,
including B, C, D, and E that are known to cause the disease.
Hepatitis A is spread through food or water contaminated with the virus or by coming in
contact with an infected person. While hepatitis A can cause a severe, acute disease, it
does not cause a chronic infection as do some of the other hepatitis viruses. If you are
exposed to hepatitis A, your immune system produces antibodies in response to the virus.
This test detects hepatitis A antibodies in the blood.
While hepatitis has many different causes, the signs and the symptoms are the same. In
hepatitis, the liver is damaged and unable to function normally. It cannot process toxins or
waste products such as bilirubin for their removal from the body. During the course of the
disease, bilirubin and liver enzyme levels in the blood can increase. While tests such as
bilirubin or a liver panel can tell your doctor that you have hepatitis, they will not tell her
what is causing it. Antibody tests for hepatitis viruses may help determine the cause.
If you are exposed to hepatitis A, your body will first produce hepatitis A IgM antibodies.
These antibodies typically develop 2 to 3 weeks after first being infected and persist for
about 2 to 6 months. Hepatitis A IgG antibodies are produced within 1 to 2 weeks of the
IgM antibodies and usually persist for life. Because hepatitis A IgM antibodies develop
early in the course of infection, a positive hepatitis A IgM test is usually considered
diagnostic for acute hepatitis A. A total hepatitis A antibody test detects the presence of
the IgM and IgG antibodies and may help determine if you have been infected in the past
and have some immunity to the disease. A test for hepatitis A IgM may be part of an acute
viral hepatitis panel that may be used to determine which virus is causing symptoms when
viral hepatitis is suspected.
A vaccine is available to help prevent hepatitis A. According to the CDC, cases of
hepatitis A have dropped by 89% since the introduction of the hepatitis A vaccine in 1995.
In 2007, just under 3000 cases of acute hepatitis A were reported, the lowest to date.
43
The Test
How is it used?
This test is used to help diagnose a liver infection due to the hepatitis A virus (HAV).
There are several causes of hepatitis and the accompanying symptoms, so this test is used
to determine if your symptoms are due to hepatitis A.
There are two versions of the test, and these are used detect two different types of hepatitis
A antibodies.
• Hepatitis A IgM is the first antibody produced by the body when it is exposed to
hepatitis A. The hepatitis A IgM test is used to screen for early detection of
infection and is used to diagnose the disease in a patients with evidence of acute
hepatitis.
• Hepatitis A IgG antibodies develop later and remain present for many years, usually
for life, and protect you against further infection by the same virus. There is no test
specifically for hepatitis A IgG antibodies; a total antibody test (which detects both
IgM and IgG antibodies) detects both current and previous infection with hepatitis
A and will also be positive after receiving the hepatitis A vaccine.
An hepatitis A antibody test may be used to screen for exposure in those who are
asymptomatic.
This test may also be used to determine if you have produced antibodies and developed
immunity in response to a hepatitis A vaccine or a previous hepatitis A infection.
In acute hepatitis, other tests such as bilirubin, liver panel, ALT, and AST may be
performed to help diagnose the condition.
When is it ordered?
Testing for the presence of IgM antibodies to hepatitis A is done when you have acute
symptoms such as:
• Fever
• Fatigue
• Nausea, vomiting, abdominal pain
• Dark urine and/or pale colored stool
• Joint pain
• Jaundice
In some people and in many young children, hepatitis A may not cause any symptoms.
This test may also be done when you are likely to have been exposed to the virus
regardless of symptoms.
If you are being considered for the hepatitis A vaccine, a total antibody test may be
ordered before you are given the vaccine to see if you need it; if the antibodies are already
present, the vaccine won't help you. Once you have completed the two doses of the
vaccine, the total hepatitis antibody test can also be used to see if you have responded to
the vaccine and developed immunity. Because almost all people respond to the vaccine,
this is not usually done.
If you have not been given the hepatitis vaccine, results of hepatitis testing indicates the
following:
44
HAV Total HAV Antibody Results Indicate
IgM (IgM and IgG)
Positive Acute HAV infection
Negative Positive No active infection, but previous HAV exposure; has
developed immunity to HAV
Positive Has been exposed to HAV but does not rule out
acute infection
Negative No current or previous HAV infection; vaccine may
be recommended if at risk
A total antibody test detects both IgM and IgG antibodies but does not distinguish between
them.
If the total antibody test or hepatitis A IgG result is positive and you have not gotten the
hepatitis A vaccine, you have had a hepatitis A infection, even if you were not aware of it.
About 30% of adults over age 40 have antibodies to hepatitis A.
If you have been given the vaccine, a positive result means you are immune to hepatitis A
and generally cannot be reinfected by it.
In the past, the only way to prevent you from developing hepatitis A after it was known
that you were exposed to the virus was to give you an injection of immune globulin. In
June 2007, guidelines in the United States were changed to recommend that you be given
the hepatitis A vaccine after exposure if you are 40 years old or younger. Not enough is
known about the effectiveness of the vaccine in age groups older than this so if you are 40
or older, you may be given immune globulin after exposure.
Although hepatitis A IgM antibodies are considered diagnostic for acute infection with
hepatitis A, there has been increasing use of the test in persons who do not have signs and
symptoms of acute hepatitis. The Centers for Disease Control and Prevention (CDC) have
recommended that the test only be used in persons who clinically have acute hepatitis to
prevent falsely positive results.
Common Questions
1. How could I have gotten the virus without knowing it?
The virus is found in contaminated water and feces. You may have eaten raw fruit or
vegetables handled by an infected person who did not wash their hands properly or you
may have eaten raw or improperly cooked seafood that had fed in contaminated waters.
Children are often infected by HAV and either do not become sick or have very mild
symptoms, such as fever and diarrhea, and are often thought to have "flu."
2. If I have hepatitis A, how long will I be contagious?
You can spread the disease to others from the time you are first infected up until
symptoms begin to appear, which can be about 4 weeks. Generally, adults are contagious
for 2 weeks after contracting the disease. However, children and individuals who are
immunocompromised may be contagious for up to 6 months.
45
3. How is hepatitis A treated?
There is no specific treatment for hepatitis A. Mild forms of the disease usually resolve on
their own and leave no lasting damage to the liver. The focus is usually on supportive
therapy, making sure you are getting enough fluids and nutrition by eating and drinking
small amounts several times a day. In rare cases, fulminant hepatitis, a life-threatening
form that causes liver failure, requires hospitalization. Hepatitis A tends to be more severe
in older persons and in those who also have chronic liver disease, so person with acute
hepatitis A in those settings will be watched more closely.
4. Is there a way to prevent hepatitis A?
Yes. There is a vaccine available. It is recommended for all children at age 1 year and for
those who are at an increased risk of exposure to the virus such as:
• children or adolescents from 2-18 years old who live in parts of the United States
where hepatitis A is common
• people traveling to developing countries with a high rate of hepatitis A
• illegal drug users
• men who have sex with men
The vaccine is also recommended for those who are at a greater risk for complications
from the disease, including people with chronic liver disease and those who have damage
to their liver from some other cause.
If it is known that you were exposed to the hepatitis A virus, you may be given the vaccine
to prevent the disease.
Hepatitis A can also be prevented with good hygiene. This includes washing hands well
after using the bathroom, after changing diapers, and before eating or starting any food
preparation.
Hepatitis B
Also known as: HBV; Hep B; anti-HBs; Hepatitis B surface antibody; HBsAg; Hepatitis
B surface antigen; HBeAg; Hepatitis B e antigen; anti-HBc; Hepatitis B core antibody;
anti-HBc, IgM; anti-HBe; Hepatitis B e antibody; HBV DNA
Formal name: Hepatitis B Virus
Related tests: Hepatitis A; Hepatitis C; Liver panel; Bilirubin; AST; ALT; GGT
Why Get Tested?
To detect, diagnose, and/or follow the course of an infection with hepatitis B virus (HBV)
or to determine if the vaccine against hepatitis B has produced the desired level of
immunity
When to Get Tested?
If you have symptoms of a hepatitis B infection or are likely to have been exposed to the
hepatitis B virus; if you have chronic liver disease due to some other cause; if you have
received the hepatitis B vaccine; if you are being treated for HBV
Sample Required?
None
46
Hepatitis B is a liver infection caused by the hepatitis B virus (HBV). It is one of several
various causes of hepatitis, a condition characterized by inflammation and enlargement of
the liver. Other causes of hepatitis include, for example, certain drugs, inherited disorders,
and autoimmune diseases. HBV is one of five "hepatitis viruses" identified so far. The
other four are A, C, D, and E.
HBV is the most common cause of acute hepatitis and the most widespread cause of
chronic viral infections worldwide (although hepatitis C virus is a more common cause in
most of North America and Europe). According to the CDC, there were about 43,000 new
cases of hepatitis B in 2007 in the U.S. However, that number is only an estimate; the
actual number of cases that were reported was much lower because many people have few
or mild symptoms and never know they have the disease. The chronic form of hepatitis B
continues to be a problem in the U.S. with about 800,000 to over 1 million people
affected. Worldwide, it is thought to affect about 350 million people and to be a factor in
the death of about 620,000 each year.
HBV is spread through contact with blood or other body fluids from an infected person.
Exposure can occur, for example, through sharing of needles for IV drug use or through
unprotected sex. People who live in or travel to areas of the world where hepatitis B is
prevalent are at a greater risk. Mothers can pass the infection to their babies, usually
during or after birth. The virus, however, is not spread through food or water, casual
contact such as holding hands, or coughing or sneezing.
The course of HBV infections can vary from a mild form that lasts only a few weeks to a
more serious chronic form lasting years. Sometimes chronic HBV leads to serious
complications such as cirrhosis or liver cancer. Some of the various stages or forms of
hepatitis B include:
• Acute infection - presence of typical signs and symptoms with positive screening
test
• Chronic infection — persistent infection with the virus detected by lab tests
accompanied by inflammation of the liver
• Carrier (inactive) state — persistent infection but no liver inflammation (a carrier is
someone who may appear to be in good health but harbors the virus and can
potentially infect others)
• "Cleared" infection — no longer any evidence of infection; viral antigen and DNA
tests are negative and no signs or symptoms of liver inflammation (although, in
many cases, the virus is present in an inactive state in the liver)
The signs and the symptoms of an acute hepatitis B infection can be very similar to those
of other types of acute hepatitis. Some of these include fever, tiredness, nausea, vomiting,
and jaundice. With hepatitis, the liver is damaged and is not able to function normally. It
cannot process toxins or waste products such as bilirubin for their removal from the body.
During the course of disease, bilirubin and liver enzyme levels in the blood may increase.
While tests such as bilirubin or a liver panel can tell your doctor that you have hepatitis,
they will not indicate what is causing it. Tests that detect infection with a hepatitis virus
may help determine the cause.
There are several different tests that can be used to detect current or previous HBV
infection. Some of the tests detect antibodies produced in response to HBV infection;
some detect viral antigens while others detect viral DNA. They can be used to screen for
47
infection in the absence of symptoms, to determine whether infection is acute or chronic,
or to monitor a chronic infection.
Though a potentially serious infection, acute HBV infection usually resolves on its own in
most adults. Infants and children tend to develop a chronic infection more often. A vaccine
is available to help prevent hepatitis B. Since routine vaccination of children was
implemented in 1990, the cases of acute hepatitis B have decreased by about 82%,
according to the CDC.
The Test
How is it used?
Hepatitis B tests may be used for a variety of reasons. Some of the tests detect antibodies
produced in response to HBV infection; some detect antigens produced by the virus, and
others detect viral DNA.
Generally, one set of tests is used to determine the cause of acute symptoms while another
set of tests may be used after a diagnosis is made, to monitor possible progression of the
disease, to detect chronic infection and/or carrier status.
The items below list the main uses for HBV tests:
• To detect acute hepatitis B infection: hepatitis B surface antigen (HBsAg), hepatitis
B core antibody (anti-HBc), IgM and sometimes hepatitis B e antigen (HBeAg)
• To diagnose chronic HBV hepatitis: HBsAg, hepatitis B virus (HBV) DNA, and
sometimes HBeAg
• To monitor chronic hepatitis B infection and its treatment: HBsAg, hepatitis B e
antigen (HBeAg), hepatitis B surface antibody (anti-HBs) IgG, hepatitis B e
antibody (anti-HBe) IgG and HBV DNA
• To detect previous exposure to hepatitis B, in a person who is immune
compromised (when the virus can become reactivated): hepatitis B core antibody
(anti-HBc) total and anti-HBs
Some of the secondary reasons to perform testing include: to screen for hepatitis B
infection in at-risk populations or in blood donors, to determine if someone is a carrier, to
detect previous infection (with subsequent immunity), and to determine if immunity has
developed due to vaccination.
Some of the tests used to screen for infection may be performed as part of an acute viral
hepatitis panel in conjunction with tests for other hepatitis viruses, including hepatitis A
(HAV) or hepatitis C (HCV).
The following table summarizes the various hepatitis B tests and their uses:
Test Description Use
Hepatitis B Protein that is present on the Often used to screen for and detect HBV
surface surface of the virus; will be infections; earliest indicator of acute hepatitis
antigen present in the blood with B and frequently identifies infected people
(HBsAG) acute and chronic HBV before symptoms appear; undetectable in the
infections blood during the recovery period; it is the
primary way of identifying those with chronic
infections.
48
Hepatitis B Antibody produced in Used to detect previous exposure to HBV; can
surface response to HBV surface also be acquired from successful vaccination.
antibody antigen; levels in the blood This test is done to determine the need for
(anti-HBs) rise during the recovery vaccination (if anti-HBs is absent) or to
phase. determine if a person has recovered from an
infections and is immune (cannot get the
infection again).
Anti- IgM antibody to the hepatitis First antibody produced after infection with
hepatitis B B core antigen (The hepatitis HBV; used to detect acute infection
core (anti- B core antigen is present only
HBc), IgM in infected liver cells; it
cannot be detected in the
blood.)
Anti- Both IgM and IgG antibodies Can be used to help detect acute and chronic
hepatitis B to hepatitis B core antigen HBV infections; it is produced in response to
core (anti- the core antigen and usually persists for life.
HBc), Total
Hepatitis B Protein produced and Unlike the surface antigen, the e-antigen is
e-antigen released into the blood by found in the blood only when the HBV virus is
(HBeAG) actively replicating hepatitis actively replicating. HBeAg is often used as a
B virus marker of ability to spread the virus to other
people (infectivity). It may also be used to
monitor the effectiveness of treatment.
However, there are some types (strains) of
HBV that do not make e-antigen; these are
especially common in the Middle East and
Asia. In areas where these strains of HBV are
common, testing for HBeAg is not very useful.
Anti- Antibody produced in In those who have recovered from acute
hepatitis Be response to the hepatitis Be hepatitis B infection, anti-HBe will be present
antibody antigen along with anti-HBc and anti-HBs. In those
(Anti-HBe) with chronic hepatitis B, anti-HBe can be used
to monitor the infection and treatment.
Hepatitis B Detects hepatitis B viral Can detect an active HBV infection; its
DNA (HBV genetic material primary use is to monitor antiviral therapy in
DNA) patients with chronic HBV infections.
While the tests described above are specific for HBV, other liver tests such as AST, ALT,
and gamma-glutamyl transferase (GGT) may be used to monitor the progress of the
disease. In some cases, a liver biopsy may be performed for confirmation.
When is it ordered?
Hepatitis B tests may be ordered when someone has signs and symptoms associated with
acute hepatitis to determine if they are due to infection with HBV. Some of these include:
49
• Fever
• Fatigue
• Abdominal pain
• Dark urine
• Pale stools
• Joint pain
• Jaundice
Hepatitis B tests may be done as follow up when routine tests results such as ALT and/or
AST are elevated. Sometimes acute forms of hepatitis may be detected this way since they
may cause only mild symptoms that can be confused with the flu. Chronic hepatitis more
often has no symptoms and is more commonly detected when routine test results are
abnormal.
A test for hepatitis B surface antigen (HBsAg) may be used for screening when someone
falls into one of the high-risk categories for chronic hepatitis B. In September 2008, the
CDC revised it guidelines and recommends the following groups be tested for HBsAg:
• People who are possible source of infection through accidental cuts, needlesticks,
etc. in health care workers
• People born in areas of the world that have a greater than 2% prevalence of HbsAg
(for example, much of Asia and Africa)
• People born in the US but were not vaccinated and whose parents are from an area
with greater than 8% prevalence of HbsAg
• Men who have sex with men
• People who have elevated liver enzymes (ALT and AST) with no known cause
• People with certain medical conditions that require that their immune system be
suppressed
• Pregnant women
• People who are in close contact with someone infected with HBV
• Those infected with HIV
In addition, some states in the US recommend that people who are in contact with the
public and who are a possible source of infection through accidental cuts, scrapes, etc. be
screened.
When hepatitis B tests are used to monitor people with chronic hepatitis B infections, they
may be performed on a regular basis. Hepatitis B surface antigen (HBsAg) and hepatitis B
e antigen (HBeAg) are usually measured about every 6 months to a year, since in some
people HBeAg (and, less commonly, HBsAg) will go away on their own. In those who are
being treated for chronic HBV, HBeAg and HBV DNA can be used to determine whether
the treatment is successful. HBV DNA will fall, usually to undetectable levels, with
successful treatment. If HBeAg was positive before treatment and becomes negative, then
treatment may sometimes be stopped after a further period of treatment, and both it and
HBV DNA may remain undetectable. If HBeAg was negative before treatment or remains
positive, then treatment is usually continued.
All donated blood is tested for the presence of the HBsAg before being distributed for
transfusion.
50
The tests for hepatitis B may be ordered individually, but are often ordered in some
combination depending on the reason for testing. Results of the tests are typically
evaluated together. Sometimes the meaning of one result depends on the result of another
test. However, not all tests are done on all people. Ask you doctor what she expects to find
out from the results of your tests. She can help you understand what the results mean.
The table below summarizes possible interpretations of some common patterns of results.
Hep B Hep B Hep B Hep B core Hep B e Hep B e Interpretation /
surface surface core antibody antigen antibody Stage of Infection
antigen antibody antibody Total (HBeAg)*See (Anti-
(HBsAg) (Anti- (Anti- (Anti-HBc note HBe)
HBs) HBc IgM) IgG+IgM)
Negative Negative Negative No active or prior
infection; not
immune — may
be good candidate
for vaccine;
possibly in the
incubation stage
Positive Negative Negative Negative Positive Negative Early acute
infection
Positive Negative Positive or Positive or Positive Negative Acute infection,
Negative Negative usually with
symptoms;
contagious
Positive Negative Positive Positive Negative* Positive Late in the acute
stage of infection
(seroconversion)
Negative Negative Positive Positive Negative* Positive Acute infection is
resolving
(convalescent)
Positive Negative Negative Positive Positive Negative Usually indicates
an active chronic
infection (liver
damage likely)
Positive Negative Negative Positive Negative* Positive Chronic infection
but low risk of
liver damage —
carrier state
Negative Positive Negative Positive Negative* Positive Infection resolved
(recovery);
51
immunity due to
natural infection
Negative Positive Negative Immunity due to
vaccination
*Note: There are some types (strains) of HBV that do not make e-antigen. In areas where
these strains of HBV are common (in the Middle East and Asia), testing for HBeAg is not
very useful. In these cases, a negative HbeAg result does not necessarily mean that the
antigen is not present or that the person is not infectious; it may be that the person is
infected with a strain that does not make the e-antigen.
Hepatitis B viral (HBV) DNA: This test measures the amount of virus present in the
blood, so results are reported as numbers, specifically, as "international units per
milliliter." A high result usually means that the virus is actively replicating and that the
infection can be passed to others. It also indicates that the person has a high risk of having
liver damage.
A low result or one that is reported as below a lower limit (for example, 100 international
units/milliliter) means the virus is not present or is present in such low numbers that it
cannot be detected. This usually means that the infection cannot be spread to others. If the
test is used to monitor treatment, a low result usually indicates the therapy is effective.
Even if you don't have symptoms, an HBV infection can damage your liver and you can
spread the infection to others. For this reason, it is important to get tested if you think you
have been exposed to HBV.
Hepatitis D (HDV) is another virus that can cause liver infections, but only if hepatits B is
also present. A person may become infected with both viruses at the same time (a co-
infection) or may first be infected with hepatitis B and then become infected with HDV (a
superinfection). In the U.S., the incidence of HDV is low. There is no vaccine for HDV,
but since it causes infections only in the presence of HBV, it may be prevented with the
HBV vaccine.
Common Questions
1. If it is possible that I have an HBV infection, will I need to have all of these tests
done?
No. Your doctor will determine which test(s) will be appropriate for your symptoms and
history.
2. Should I get the HBV vaccine?
Yes. Unless there is something in your medical history to the contrary, it is prudent to get
the series of vaccinations. Babies, children and adolescents are routinely given the series
of shots. The Centers for Disease Control and Prevention recommends that adults in high
risk groups get vaccinated. Some of these groups include those in close contact with
someone who has hepatitis B, dialysis patients, people with chronic liver or kidney
disease, people with HIV or who seek treatment for other sexually transmitted diseases or
drug treatment, and those who travel to countries where hepatitis B is common.
3. How is hepatitis B treated?
There is no specific treatment for acute hepatitis B infections. Symptoms are usually
treated with supportive care. This usually involves making sure that you are getting plenty
52
of rest and enough fluids and nutrition by eating and drinking small amounts several times
a day.
Chronic forms of hepatitis B may be treated with antiviral medications such as interferon,
entecavir, tenofovir, lamivudine, and adefovir. However, some antiviral drugs can have
serious side effects and not all people need to be treated. Often, people with chronic
hepatitis will be closely monitored to see if they develop cirrhosis or liver cancer. It is
important to talk to your doctor about your treatment options and the risks and benefits of
those currently available.
Hepatitis C
Also known as: Hepatitis C antibody; anti-HCV; HCV recombinant immunoblot assay;
HCV RIBA; HCV-RNA; Hepatitis C viral load
Formal name: Viral Hepatitis C
Related tests: Hepatitis A; Hepatitis B; Liver Panel; ALT; AST; GGT, Bilirubin
Why Get Tested?
To screen for and diagnose a hepatitis C virus (HCV) infection and to monitor treatment of
the infection
When to Get Tested?
When you may have been exposed to the hepatitis C virus, such as through contact with
infected blood, have symptoms associated with liver disease, or have risk factors for
hepatitis C infection
Sample Required?
None
Hepatitis C (HCV) is a virus that causes an infection of the liver that is characterized by
liver inflammation and damage. It is one of five "hepatitis viruses" identified so far,
including A, B, D, and E, that are known to cause the disease. HCV is spread by exposure
to contaminated blood, primarily though the sharing of needles by intravenous drug users,
but also by sharing personal items contaminated by blood such as razors, through sex with
an infected person, via health care occupational exposure, and from mother to baby during
childbirth. Before tests for HCV became available in the 1990s, HCV was often
transmitted by blood transfusions. While HCV is not as contagious as Hepatitis B, there is
currently no vaccine to prevent infection. Hepatitis C infection is a common cause of
chronic liver disease in North America; about 2% of all adults in the United States have
been exposed to the virus, and up to 85% of those who have it will become chronically
infected after their acute infection resolves.
According to the CDC, an estimated 3.2 million people in the U.S. have a chronic HCV
infection. Many of those who are infected have no symptoms and are not aware of the
condition. The acute HCV infection may cause few to mild nonspecific symptoms, and the
chronic infection may simmer quietly for a decade or two before causing sufficient liver
damage to affect liver function.
Hepatitis C infections cause increased risk of developing some other serious conditions:
53
• About 60-70% of those infected will develop chronic liver disease.
• About 20-30% will develop cirrhosis over 20 years; recent projections suggest that
almost 45% will eventually develop cirrhosis.
• HCV can cause death in about 1-5% of those infected.
Hepatitis C tests are a group of tests that are performed to detect, diagnose, and monitor
the treatment of a hepatitis C viral infection. The most common test for HCV looks for
antibodies in your blood that are produced in response to an HCV infection. Other tests
detect the presence of viral RNA, the amount of viral RNA present, or determine the
specific subtype of the virus.
The Test
How is it used?
Hepatitis C tests are used to detect and diagnose an infection and/or to monitor the
treatment of hepatitis C virus (HCV). Tests are used to detect the condition if a person:
• Has been exposed to someone with HCV
• Participates in high risk behaviors such as injecting street drugs
• Has abnormal liver function tests
• Has symptoms associated with liver disease, such as jaundice, dark urine, nausea, or
unexpected weight gain or loss
The following tests may be used to screen for and/or detect HCV:
• Anti-HCV test detects the presence of antibodies to the virus, indicating exposure
to HCV. This test cannot distinguish between someone with an active or a previous
HCV infection. Usually, the test is reported as "positive" or "negative." There is
some evidence that if the test is "weakly positive," it may be a false positive. The
Centers for Disease Control and Prevention (CDC) suggests that weakly positive
tests be confirmed with the HCV RIBA test before being reported.
• HCV recombinant immunoblot assay (RIBA) test is an additional test ordered to
confirm the presence of HCV antibodies. In most cases, it can tell if the positive
anti-HCV test was due to exposure to HCV (positive RIBA) or represents a false
signal (negative RIBA). In a few cases, the results cannot answer this question
(indeterminate RIBA). Like the anti-HCV test, the RIBA test cannot distinguish
between a current or past infection.
The following tests may be used to diagnose a current infection and to guide and monitor
treatment:
• HCV RNA test, Qualitative may be used to distinguish between a current or past
infection. It is reported as a "positive" or "detected" if any HCV viral RNA is found;
otherwise, the report will be "negative" or not detected." It may also be ordered after
HCV treatment is complete to see if the virus has been eliminated from the blood.
These tests are seldom used any more.
• HCV Viral Load (HCV RNA test, Quantitative) detects and measures the number
of viral RNA particles in the blood. Viral load tests are often used before and during
treatment to help determine response to treatment by comparing the amount of virus
before and during treatment (usually at several time points in the first three months
of treatment). Successful treatment causes a decrease of 99% or more (2 logs) in
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viral load soon after starting treatment (as early as 4-12 weeks) and usually leads to
viral load being not detected even after treatment is completed. Some newer viral
load tests can detect very low amounts of viral RNA.
• Viral genotyping is used to determine the kind, or genotype, of the HCV virus
present. There are 6 major types of HCV; the most common (genotype 1) is less
likely to respond to treatment than genotypes 2 or 3 and usually requires longer
therapy (48 weeks versus 24 weeks for genotype 2 or 3). Genotyping is often
ordered before treatment is started to give an idea of the likelihood of success and
how long treatment may be needed.
When is it ordered?
The CDC recommends screening for HCV infections in the following cases:
• If you have ever injected illegal drugs
• If you received a blood transfusion or organ transplant before July 1992*
• If you have received clotting factor concentrates produced before 1987
• If you were ever on long-term dialysis
• For children born to HCV-positive women
• For health care, emergency medicine, and public safety workers after needlesticks,
sharps, or mucosal exposure to HCV-positive blood
• For people with evidence of chronic liver disease
*The blood supply has been monitored in the U.S. since 1992, and any units of blood that
test positive for HCV are rejected for use in another person. The current risk of HCV
infection from transfused blood is about 1 case per two million transfused units.
Most people newly infected with HCV have no symptoms or ones that are so mild that
they rarely prompt a person to visit a doctor and get tested for HCV. However, about 10-
20% of people may experience symptoms such as fatigue, pain in the abdominal area,
decreased appetite, and jaundice and may be tested for HCV.
A positive anti-HCV test may be confirmed with an HCV RIBA test, especially when the
anti-HCV test is "weakly positive." Many physicians do not use RIBA since it still does
not determine if a person is currently infected. Quantitative HCV-RNA is often ordered
when the antibody test is positive to see if the infection is still present. HCV viral load and
genotyping may be done when treatment is planned; viral load may be ordered
periodically to monitor response to treatment and at the completion of treatment to
evaluate its effectiveness.
Interpretation of the HCV tests is shown in the table below. In general, if the HCV
antibody test is strongly positive, then someone has likely been infected at some time with
hepatitis C. If the HCV RNA test is positive, then the person has a current infection. If no
HCV viral particles are detected, then the person either does not have an active infection
or the virus is present in very low numbers.
Test results to detect, diagnose, and monitor HCV include:
Anti-HCV HCV RIBA HCV RNA, HCV Infection
Qualitative
Negative No infection or, rarely,
insufficient antibody
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Positive Negative No infection; likely a false
positive
Positive Need to do Negative Likely no infection, past
infection, or HCV viral load
low
Positive Positive Negative Past infection or HCV viral
load low
Positive or Weak or Not done or Positive Current infection
Indeterminate Positive
Indeterminate or Indeterminate Negative No infection, past infection, or
Positive HCV viral load low
An HCV viral load (HCV RNA quantitative) can indicate whether or not treatment is
effective. A high or increasing viral load may be a sign that treatment is not successful
whereas a low, decreasing, or undetectable viral load may imply that the treatment is
working. According to the CDC, an undetectable viral load in a treated person's blood for
24 weeks after the end of the treatment means that the HCV infection has responded to
therapy.
The results of the HCV genotype test identifies which type of HCV the person has and
helps guide the type and often the length of treatment. There are at least six separate types
(genotypes) of HCV numbered as 1 through 6 with at least an additional 50 subtypes that
have been identified. Genotype 1 is the most common HCV genotype in the United States.
HCV antibodies usually do not appear until several months into an infection but will
always be present in the later stages of the disease.
About 25% of those with HIV/AIDS also have an HCV co-infection, and their liver
disease is likely to progress at an accelerated rate.
Common Questions
1. If the disease is very mild, why should I be tested?
Hepatitis C often leads to chronic hepatitis, which can progress to cirrhosis and liver
cancer (hepatocellular carcinoma). Early detection of the virus can alert your doctor to
follow your liver function more closely than usual and to consider treating you if you are
chronically infected.
2. Are there other tests used to follow the disease?

Yes. Liver tests, such as ALT and AST, are used to indicate ongoing liver injury. Persons
who are still infected with HCV but always have normal AST and ALT probably have
very mild liver disease and may not need treatment. Other liver tests, such as albumin,
prothrombin time, and bilirubin can also be used; they are typically normal unless the
person has developed cirrhosis. Sometimes a liver biopsy may be performed to determine
how severe the liver damage is.
3. Can I be vaccinated against HCV?
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No. Currently, there is no vaccine available. Developing one has been difficult because the
virus has several different molecular configurations, which are constantly changing.
4. Once I have recovered from HCV, can I get infected again?
Yes. A prior infection with HCV does not protect you from another infection; it does not
make you immune to HCV. Most people do not have an effective immune response to the
virus. Changes that the virus undergoes as it replicates during an infection make it difficult
for the body to fight against the initial or subsequent infections.
5. Is there treatment for HCV?
Yes, there are currently a few drugs that can be used to treat HCV infection. Most
commonly, a combination of two drugs (pegylated interferon and ribavirin) is used. New
drugs to treat HCV are being tested currently. Depending on your age, gender, the type
and viral load of HCV you have and how much damage has occurred to your liver, your
likelihood of cure from HCV may range from very low to as high as 80%.
6. Can I test myself for the virus at home?
There is an FDA-approved test kit available for collecting samples to send to a laboratory
for testing. Confidential test results are provided over the telephone. You cannot actually
perform the test yourself at home.
7. How can I tell if I can spread the infection to others?
If a person has detectable HCV RNA in their blood, they have the potential to spread the
disease to other people. Hepatitis C is spread by exposure to contaminated blood. Some
mechanisms of exposure include the sharing of needles or other 'works' used in consuming
drugs such as cocaine or heroin; use of contaminated equipment for activities such as body
piercing and tattooing; occupational exposure of healthcare workers to used needles or
other sharp objects; through sexual activity that results in tissue tears; from mother to baby
during childbirth; or from cuts sustained during athletic or other activity.
HIV Antibody
Also known as: AIDS test; AIDS screen; HIV serology
Formal name: Human immunodeficiency virus antibody test
Related tests: p24 antigen test; CD4 and CD8; HIV viral load; HIV genotypic resistance
testing
Why Get Tested?
To determine if you are infected with Human immunodeficiency virus (HIV)
When to Get Tested?

One month to three months after you think you may have been exposed to the virus; the
average time for the antibody to be detected is two weeks after exposure to the virus
Sample Required?
A blood sample collected from a vein in your arm; there are also tests available that can be
performed on urine and/or oral fluid
None
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This test detects HIV antibodies in blood or other body fluids. HIV, human
immunodeficiency virus, is the virus that causes AIDS (acquired immunodeficiency
syndrome), which destroys the immune system and leaves the body vulnerable to
debilitating infections. When HIV enters the body, such as through contact with an
infected individual or contaminated needle, the immune system responds by producing
antibodies directed against the virus. These antibodies can be detected about 3 to 8 weeks
after exposure to the virus. If exposure to the virus is more recent, then antibody levels
may be too low to detect. It may be necessary to perform a p24 antigen test or an HIV
RNA (viral load) test in order to detect the virus.
The Test
How is it used?
HIV antibody testing is used to screen for and diagnose HIV infections. Early treatment of
HIV infection and immune system monitoring can greatly improve long-term health. Also,
knowing your HIV status may help you change behaviors that would put you and others at
risk.
Antibodies to the HIV virus are often detected by a screening test called an ELISA. The
ELISA test is repeated if positive. The ELISA method is very sensitive but requires
another test, a Western Blot, to confirm the results because false positives can occur.
These tests can be done on blood, urine or oral sample in a doctor’s office or a local clinic.
There are several rapid tests available in which results are generated in about 20 minutes.
However, these too must have confirmatory testing before a final diagnosis can be made.
There is also a home collection kit approved by the US Food and Drug Administration
(FDA) that is available for HIV antibody testing. This allows you to take a sample of your
blood from a finger at home and mail it to a testing center. You would then hear your
results later over the phone, along with appropriate counseling. There are, however, no
available tests that can be performed at home. (For more, see the article on Home Testing
and the FDA webpage on HIV home tests.)
When is it ordered?
Several organizations, including the Centers for Disease Control (CDC), American
College of Physicians (ACP), and HIV Medicine Association (HMA) recommend that
anyone over the age of 13 be screened for HIV.
Antibody testing for HIV is especially important if you are in a high risk group or if you
think you may have been exposed to HIV. Testing is recommended if:
• You are sexually active (three or more sexual partners in the last 12 months).
• You received a blood transfusion prior to 1985, or a sexual partner received a
transfusion and later tested positive for HIV. For more information, see the CDC
webpage How safe is the blood supply in the US?
• You are uncertain about your sexual partner’s risk behaviors.
• You are a male who has had sex with another male.
• You have used street drugs by injection, especially when sharing needles and/or
other equipment.
• You have a sexually transmitted disease (STD).
• You are a health care worker with direct exposure to blood on the job.
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• You are pregnant. (There are now treatments that can greatly reduce the risk that a
pregnant woman who has HIV will give the virus to her baby.)
• You are a woman who wants to make sure you are not infected with HIV before
getting pregnant (see Pregnancy: Pre-conception, HIV).
A healthy individual has no antibodies to HIV. However, a negative screening test means
only that there is no evidence of disease at the time of the test. It is important for those
who are at increased risk of HIV infection to have screening tests performed on a regular
basis to check for possible exposure to the virus.
If you test positive for HIV antibodies on both the ELISA and the Western Blot tests, you
are considered to be infected with HIV. HIV cannot be cured, but early diagnosis allows
for treatment that can help to suppress levels of virus in your body (viral load) and slow
progression of the disease.
Antibody testing will not detect HIV immediately after exposure, during the window
before the development of antibodies. If you are tested too soon, your result may be
negative despite the fact that you are infected (false negative). In this case, you may be
tested using a p24 antigen test that can detect actual viral protein in the blood 1 to 3-4
weeks after exposure or an HIV RNA test (viral load) that detects the presence of the
virus, not the antibody response to it. Or you should have another HIV antibody test in 3–6
months from the time of a possible exposure to the virus.
Common Questions
1. What are the symptoms of HIV infection?
The only reliable way to tell if you are infected with HIV is to get tested. This is because
many people with HIV do not experience symptoms for years after the initial infection or
have symptoms that are very similar to symptoms of other illnesses. Click here for
information from the CDC on symptoms of HIV infection.
2. When does AIDS develop?
Symptoms of the initial HIV infection can mimic those of influenza and other viral
infections. The term AIDS applies to the most advanced stages of HIV infection.
According to the CDC, AIDS is diagnosed when your CD4 T-cell count drops below 200
cells per cubic millimeter of blood or when you have HIV and an AIDS-related illness
such as tuberculosis. Click here for more information from the CDC.
3. What are the treatments for HIV/AIDS?

Currently, there is no cure for HIV or AIDS. However, there are therapies that can help.
The CDC’s booklet, Living with HIV/AIDS, is available online. The FDA also offers an
online list of FDA-approved therapies. Early treatment is recommended.
4. Should I tell anyone else of my test results?
Yes. If you test positive for HIV, it is important that you tell your health care providers as
well as all current and future sex partners and/or anyone with whom you share needles.
Counseling services are often available from the clinic that performed the test or from your
health care provider that will help you to inform the people who need to know.
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5. How confidential are HIV test results?
Your HIV status, like other medical conditions and test results, is protected by the HIPAA
Privacy Rule and cannot be shared with friends, family, or employers without your written
permission. Your HIV status may be shared with your health care providers who have a
“need to know” in order to treat you. Also, in order to determine the incidence of HIV and
to provide appropriate prevention and care services, all new cases of HIV are reported to
state and local health departments.
Certain testing centers provide either anonymous (your name is never given) or
confidential (your name is given but kept private) HIV testing and counseling. The FDA
has approved one home testing device that allows you to remain anonymous and to get
confidential results. You can also contact your state, county, or city health department to
find out where testing may be available.
6. Can you use the HIV antibody test to detect HIV in newborns?
No. Because maternal antibodies are transferred from mother to baby and stay in the
newborn’s system for 6–12 months, a different test must be used. This test is called the
HIV DNA test (see FAQ #2 here).
7. Are there HIV testing methods other than a blood test?
Yes. Methods that test either oral fluid or urine are available in some locations. The CDC
has more information on the different types of HIV screening tests available in the U.S.
(click here).
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Widal test
The Widal test is a presumptive serological test for enteric fever or undulant fever. In
case of Salmonella infections, it is a demonstration of agglutinating antibodies against
antigens O-somatic and H-flagellar in the blood. For brucellosis, only O-somatic antigen is
used.
The Widal test is not a very specific test, since patients are often exposed to other bacteria
(e.g. Salmonella enteritidis, Salmonella typhimurium and some types of E. coli) in this
species that induce cross-reactivity; many people have antibodies against these enteric
pathogens, which also react with the antigens in the Widal test, causing a false-positive
result. Test results need to be interpreted carefully in the light of past history of enteric
fever, typhoid vaccination, and the general level of antibodies in the populations in
endemic areas of the world. Typhidot is the other test used to ascertain the diagnosis of
typhoid fever. As with all serological tests, the rise in antibody levels needed to make the
diagnosis takes 7-14 days, which limits their use. Other means of diagnosing Salmonella
typhi (and paratyphi) include cultures of blood, urine and faeces. The organism also
produces H2S from thiosulfate.
Often 2-mercaptoethanol is added. This agent more easily denatures the IgM class of
antibodies, so if a decrease in the titer is seen after using this agent, it means that the
contribution of IgM has been removed leaving the IgG component. This differentiation of
antibody classes is important; as it allows for the distinction of a recent (IgM) from an old
infection (IgG)
The Widal test is positive if TO antigen titer is more than 1:160 in an active infection, or if
TH antigen titer is more than 1:160 in past infection or in immunized persons. A single
Widal test is of little clinical relevance due to the number of cross reacting infections,
including malaria. If no other tests (either bacteriologic culture or more specific serology)
are available, a four fold increase in the titer (e.g., from 1:40 to 1:160) in the course of the
infection, or a conversion from an IgM reaction to an IgG reaction of at least the same
titer, would be consistent with a typhoid infection.
The Widal test is "a test involving agglutination of typhoid bacilli when they are mixed
with serum containing typhoid antibodies from an individual having typhoid fever; which
may be used to detect the presence of Salmonella typhi and S. paratyphi."
Titer
A titer (or titre) is a measure of concentration. Titer testing employs serial dilution to
obtain approximate quantitative information from an analytical procedure that inherently
only evaluates as positive or negative. The titer corresponds to the highest dilution factor
that still yields a positive reading. For example, positive readings in the first 8 serial
twofold dilutions translate into a titer of 1:256 (i.e, 2−8). A specific example is a viral titer,
which is the lowest concentration of virus that still infects cells. To determine the titer,
several dilutions are prepared, such as 10−1, 10−2, 10−3,...,10−8.
Many traditional serological tests such as hemagglutination or complement fixation
employ this principle. Such tests can typically be read visually, which makes them fast and
cost-effective in a "low-tech" environment. The interpretation of serological titers is
61
guided by reference values that are specific for the antigen or antibody in question; a titer
of 1:32 may be below the cut-off for one test but above for another.
The titer of a fat is the temperature, in degrees Celsius, at which it solidifies. The higher
the titer, the harder the fat. This titer is used in determining whether an animal fat is
considered tallow (titer higher than 40 °C) or a grease (titer below 40 °C).[1]
A titer (when referring to a library titration) is the number of plaque forming units per
millimeter. The reason why the titer is important is because we need to make sure that the
library has enough viable phage particles to represent all of the original genome. Also, a
certain phage density needs to be plated in order to be able to screen the library
successfully
Brucella
Alternative Names
Brucella serology; Brucella antibody test or titer
How the Test Is Performed
Blood is typically drawn from a vein, usually from the inside of the elbow or the back of
the hand. The site is cleaned with germ-killing medicine (antiseptic). The health care
provider wraps an elastic band around the upper arm to apply pressure to the area and
make the vein swell with blood.
Next, the health care provider gently inserts a needle into the vein. The blood collects into
an airtight vial or tube attached to the needle. The elastic band is removed from your arm.
Once the blood has been collected, the needle is removed, and the puncture site is covered
to stop any bleeding.
In infants or young children, a sharp tool called a lancet may be used to puncture the skin
and make it bleed. The blood collects into a small glass tube called a pipette, or onto a
slide or test strip. A bandage may be placed over the area if there is any bleeding.
The blood is then tested in a laboratory to look for antibodies. For Brucella, the serum
agglutination test (SAT) is the simplest and most widely used testing method.
How to Prepare for the Test
There is no special preparation.
How the Test Will Feel
When the needle is inserted to draw blood, some people feel moderate pain, while others
feel only a prick or stinging sensation. Afterward, there may be some throbbing.
Why the Test Is Performed
This test may be performed when the doctor suspects brucellosis.
Normal Results
A normal result shows no antibodies to Brucella . However, during the first few days to
weeks of exposure to an antigen, there may be very little antibody production. Therefore, a
serology test may not detect early stage disease.
As brucellosis progresses, more antibodies will be present. If the health care provider
suspects brucellosis, you may need to have the test repeated 10 days to 2 weeks after the
first test to watch for this rise.
Infection with other bacteria, such as Yersinia , Francisella , and Vibrio , and
immunizations can make the test falsely positive.
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Normal value ranges may vary slightly among different laboratories. Talk to your doctor
about the meaning of your specific test results.
What Abnormal Results Mean
If the test detects antibodies, you have likely been exposed to the Brucella bacteria
(possible brucellosis).
Risks
Veins and arteries vary in size from one patient to another and from one side of the body
to the other. Obtaining a blood sample from some people may be more difficult than from
others.
Other risks associated with having blood drawn are slight but may include:
• Excessive bleeding
• Fainting or feeling light-headed
• Hematoma (blood accumulating under the skin)
• Infection (a slight risk any time the skin is broken)
Considerations
A serology test can determine if you have ever been exposed to a particular antigen, but
this does not necessarily mean that you are currently infected. Increasing antibody levels
over a 2-week period are more likely to indicate a current infection.
Rheumatoid Factor
Also known as: RF
Formal name: Rheumatoid Factor
Related tests: ANA, Autoantibodies, CCP (Cyclic Citrullinated Peptide Antibody), ESR,
CRP, ENA panel, Synovial Fluid Analysis
Why Get Tested?
To help diagnose rheumatoid arthritis (RA) and Sjögren's syndrome
When to Get Tested?
When you have fatigue, joint pain, weakness, or dry eyes or dry mouth that your doctor
suspects may be due to RA or Sjögren's syndrome
Sample Required?
None
This test detects and measures rheumatoid factor (RF) in the blood. RF is an autoantibody,
an IgM (immunoglobulin M) protein that is produced by the body's immune system.
Autoantibodies attack a person's own tissues, mistakenly identifying the tissue as
"foreign." While the biologic role of RF is not well understood, its presence is useful as an
indicator of inflammatory and autoimmune activity.
The RF test is a valuable test for confirming rheumatoid arthritis (RA) or Sjögren's
syndrome, but it can be positive in other conditions too. About 75% of those with RA and
as many as 60-70% of those with Sjögren's syndrome will have a positive RF test.
However, RF may also be detected in people with a variety of other disorders, such as
63
persistent bacterial, viral, and parasitic infections, and certain cancers. It may sometimes
be seen in those with lung disease, liver disease, and kidney disease, and it can be found in
a small percentage of healthy people.
The Test
How is it used?
The rheumatoid factor (RF) test is primarily used to help diagnose rheumatoid arthritis
(RA) or Sjögren's syndrome and to help distinguish them from other forms of arthritis or
other conditions that cause similar symptoms. While diagnoses of RA and Sjögren's
syndrome rely heavily on the clinical picture, some of the signs and symptoms may not be
present or follow a typical pattern, especially early in these diseases. Furthermore, the
signs and symptoms may not always be clearly identifiable since people with these
diseases may also have other connective tissue disorders or conditions, such as Raynaud's
phenomenon, scleroderma, autoimmune thyroid disorders, and systemic lupus
erythematosis, and display symptoms of these disorders as well. The RF test is one tool
among others that can be used to help make a diagnosis when RA or Sjörgren's syndrome
is suspected.
The RF test may be ordered along with other autoimmune-related tests, such as an ANA
(antinuclear antibody), and other markers of inflammation, such as a CRP (C-reactive
protein) and ESR (erythrocyte sedimentation rate), as well as a CBC (Complete Blood
Count) to evaluate the body's blood cells. A CCP (Cyclic Citrullinated Peptide Antibody)
test, a relatively new test that can help detect early RA, may be ordered if the RF is
negative.
The RF test may also be ordered, along with tests such as anti-SS-A and anti-SS-B to help
diagnose Sjögren's syndrome.
When is it ordered?
The test for RF may be ordered when a person has signs of RA. Symptoms may include
pain, warmth, swelling, and morning stiffness in the joints, nodules under the skin, and, if
the disease has progressed, evidence on X-rays of swollen joint capsules and loss of
cartilage and bone. An RF test may be repeated when the first test is negative and
symptoms persist.
The RF test also may be ordered when a patient has symptoms suggesting Sjögren's
syndrome. Symptoms may include an extremely dry mouth and eyes, dry skin, and joint
and muscle pain.
The RF test must be interpreted in conjunction with a person's symptoms and clinical
history to make a diagnosis of RA, Sjögren's syndrome, or another condition.
In those with symptoms and clinical signs of rheumatoid arthritis, the presence of
significant concentrations of RF indicates that it is likely that they have RA. In people
with the symptoms of Sjögren's syndrome, significant concentrations of RF indicate that it
is likely that they have Sjögren's.
A negative RF test does not rule out RA or Sjögren's syndrome. About 20% of people with
RA and many of those with Sjögren's syndrome will be persistently negative for RF and/or
may have very low levels of RF.
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Positive RF test results may also be seen in healthy people and in people with conditions
such as: endocarditis; systemic lupus erythematosus (lupus); tuberculosis; syphilis;
sarcoidosis; cancer; viral infection; or disease of the liver, lung, or kidney. The RF test is
not used to diagnose or monitor these other conditions.
The frequency of false positive RF results (occurring in people who do not have RA or
Sjogren's syndrome) increases with age.
Common Questions
1. Does a high amount of RF mean that I have a bad case of arthritis?
High concentrations of RF may persist or fluctuate and do not necessarily correlate with
the severity of signs or symptoms. While it is true that high amounts of this autoantibody
are often found in people with active cases of rheumatoid arthritis, high RF levels may
also result from Sjögren's syndrome or other inflammatory conditions. Increased RF levels
in your blood may also mean that you have endocarditis; systemic lupus erythematosus
(lupus); tuberculosis; syphilis; sarcoidosis; cancer; viral infection; or a disease of the liver,
lung, or kidneys.
2. Does everyone need an RF test?
The RF test is not routinely ordered. Most people will never need to have an RF test
performed.
3. Can I have arthritis and not have Rheumatoid Arthritis (RA)?
Yes, you may have another type of arthritis, such as osteoarthritis. Osteoarthritis is the
most common form of arthritis in the U.S. and is associated with the aging process, joint
damage, and joint deterioration, not with autoimmune tissue destruction.
4. Can an RF test be performed in my doctor's office?
It could be performed in your doctor's office, but in most cases the test will be sent to the
laboratory.
ANA
Also known as: Antinuclear Antibody test; Fluorescent Antinuclear Antibody; FANA
Formal name: Antinuclear Antibody Test
Related tests: Extractable Nuclear Antigen Antibodies (ENA Panel); Autoantibody tests
Why Get Tested?
To screen for certain autoimmune disorders, such as systemic lupus erythematosus (SLE),
polymyosistis, and a number of others
When to Get Tested?
If your doctor thinks that you have symptoms of an autoimmune disorder
Sample Required?
None needed; however, some drugs interfere with the test, so tell your doctor about any
medications you are taking.
65
The ANA test identifies the presence of antinuclear antibodies (ANA) in the blood. ANA
is a group of special antibodies produced by a patient’s immune system when it fails to
adequately distinguish between “self” and “nonself." These autoantibodies attack the
body’s own cells, causing signs and symptoms such as tissue and organ inflammation,
joint and muscle pain, and fatigue. The presence of ANA is a marker of an autoimmune
process and is associated with several autoimmune disorders but is most commonly seen
in the autoimmune disorder systemic lupus erythematosus (SLE).
No test preparation is needed; however, some drugs interfere with the test, so tell your
doctor about any medications you are taking.
The Test
How is it used?
The ANA test is ordered to help screen for autoimmune disorders and is most often used
as one of the tests to diagnose systemic lupus erythematosus (SLE). Depending on the
patient's symptoms and the suspected diagnosis, ANA may be ordered along with one or
more other autoantibody tests. Other laboratory tests associated with presence of
inflammation, such as erythrocyte sedimentation rate (ESR) and/or C-reactive protein
(CRP) may also be ordered. ANA may be followed by additional tests that are considered
subsets of the general ANA test and that are used in conjunction with the patient's clinical
history to help rule out a diagnosis of other autoimmune disorders.
When is it ordered?
The ANA test is ordered when a patient shows signs and symptoms that are associated
with SLE or another autoimmune disorder. It may also be ordered when a patient has been
diagnosed with an autoimmune disorder and the doctor suspects that the patient may have
developed an additional autoimmune disorder. Patients with autoimmune disorders can
have a wide variety of symptoms such as low-grade fever, joint pain, fatigue, and/or
unexplained rashes that may change over time.
ANA tests are performed using different assays (indirect immunofluorescence microscopy
or by enzyme-linked immunoabsorbant assay - ELISA) and results are reported as a titer
with a particular type of immunofluroscence pattern (when positive). Low-level titers are
considered negative, while increased titers, such as 1:320, are positive and indicate an
elevated concentration of antinuclear antibodies.
ANA shows up on indirect immunofluorescence as fluorescent patterns in cells that are
fixed to a slide that is evaluated under a microscope. Different patterns are associated with
a variety of autoimmune disorders. Some of the more common patterns include:
• Homogenous (diffuse) - associated with SLE and mixed connective tissue disease
• Speckled - associated with SLE, Sjogren's syndrome, scleroderma, polymyositis,
rheumatoid arthritis, and mixed connective tissue disease
• Nucleolar - associated with scleroderma and polymyositis
• Outline pattern (peripheral) -associated with SLE
An example of a positive result might be: "Positive at 1:320 dilution with a homogenous
pattern."
A positive ANA test result may suggest an autoimmune disease, but further specific
testing is required to assist in making a final diagnosis. ANA test results can be positive in
66
people without any known autoimmune disease. While this is not common, the frequency
of a false positive ANA result increases as people get older.
Also, ANA may become positive before signs and symptoms of an autoimmune disease
develop, so it may take time to tell the meaning of a positive ANA in a person who does
not have symptoms. Most positive ANA results don't have significance, so physicians
should reassure their patients but should also still be vigilant for development of signs and
symptoms that might suggest an autoimmune disease.
About 95% of SLE patients have a positive ANA test result. If a patient also has
symptoms of SLE, such as arthritis, a rash, and autoimmune thrombocytopenia, then he
probably has SLE. In cases such as these, a positive ANA result can be useful to support
SLE diagnosis. Two subset tests for specific types of autoantibodies, such as anti-dsDNA
and anti-SM, may be ordered to help confirm that the condition is SLE.
A positive ANA can also mean that the patient has drug-induced lupus. This condition is
associated with the development of autoantibodies to histones, which are water soluable
proteins rich in the amino acids lysine and arginine. An anti-histone test may be ordered to
support the diagnosis of drug-induced lupus.
Other conditions in which a positive ANA test result may be seen include:
• Sjögren's syndrome: Between 40% and 70% of patients with this condition have a
positive ANA test result. While this finding supports the diagnosis, a negative result
does not rule it out. The doctor may want to test for two subsets of ANA: Anti-SS-A
(Ro) and Anti-SS-B (La). The frequency of autoantibodies to SSA in patients with
Sjögren's can be 90% or greater.
• Scleroderma: About 60% to 90% of patients with scleroderma have a positive ANA
finding. In patients who may have this condition, ANA subset tests can help
distinguished two forms of the disease, limited versus diffuse. The diffuse form is
more severe. Limited disease is most closely associated with the anticentromere
pattern of ANA staining (and the anticentromere test), while the diffuse form is
associated with autoantibodies to the anti–Scl-70.
• A positive result on the ANA also may show up in patients with Raynaud's disease,
rheumatoid arthritis, dermatomyositis, mixed connective tissue disease, and other
autoimmune conditions.
A doctor must rely on test results, clinical symptoms, and the patient’s history for
diagnosis. Because symptoms may come and go, it may take months or years to show a
pattern that might suggest SLE or any of the other autoimmune diseases.
A negative ANA result makes SLE an unlikely diagnosis. It usually is not necessary to
immediately repeat a negative ANA test; however, due to the episodic nature of
autoimmune diseases, it may be worthwhile to repeat the ANA test at a future date.
Aside from rare cases, further autoantibody (subset) testing is not necessary if a patient has
a negative ANA result.
Some drugs and infections as well as other conditions mentioned above can give a false
positive result for the ANA test.
About 3% - 5% of Caucasians may be positive for ANA and it may reach as high as 10% -
37% in healthy individuals over the age of 65.
67
Some medications may bring on a condition that includes SLE symptoms, called drug-
induced lupus. When the drugs are stopped, the symptoms usually go away. Although
many medications have been reported to cause drug-induced lupus, those most closely
associated with this syndrome include hydralazine, isoniazid, procainamide, and several
anticonvulsants.
Common Questions
1. Why is it called “antinuclear” antibody?
ANA are autoantibodies that are directed against certain components found in the nucleus
(center) of a cell.
2. My doctor told me my ANA test is positive, but he isn’t sure if I have lupus. How
can this be?
A positive ANA result means that you have a higher than “normal” concentration of these
antibodies. This is one of the tools in diagnosing lupus as well as several other
autoimmune diseases, so a positive result may be related to lupus or another disease. Or
you may simply have a higher than normal concentration of these autoantibodies that may
not have any impact on your health. Even among people with lupus, these results can vary
widely; one person can be in remission at a certain titer of ANA while another can be
extremely ill at the same titer. Autoimmune diseases often have a systemic effect on the
body and are very complex by nature. Interpreting what these results mean for you is the
work of your doctor. And your doctor may need to compare your test results as well as the
severity of your symptoms over a period of time in order to make a definitive diagnosis.
This additional time may also allow your doctor the opportunity to eliminate other
possible causes for your symptoms.
3. Is SLE the same thing as lupus?
There are actually several forms of lupus. SLE is the form that is most commonly referred
to when someone mentions “lupus.” Systemic lupus means that it can attack almost any
organ or system in your body. This is the most severe form. There are other forms of lupus
that are primarily limited to skin, and their symptoms include rashes that may be found in
many shapes and locations on the body. A butterfly-shaped rash is commonly seen on or
near the face.
C-Reactive Protein
Also known as: CRP
Formal name: C-Reactive Protein
Related tests: High-sensitivity C-reactive protein (hs-CRP); Erythrocyte sedimentation
rate (ESR)
Why Get Tested?

To identify the presence of inflammation and to monitor response to treatment [Note: to
test for your risk of heart disease, a more sensitive test (hs-CRP) is used.]
When to Get Tested?
68
When your doctor suspects that you might be suffering from an inflammatory disorder (as
with certain types of arthritis and autoimmune disorders or inflammatory bowel disease) or
to check for the presence of infection (especially after surgery)
Sample Required?
A blood sample taken from a vein in your arm
C-reactive protein (CRP) is an acute phase reactant, a substance made by the liver and
secreted into the bloodstream within a few hours after the start of an infection or
inflammation. Increased levels are observed after a heart attack, in sepsis, and after a
surgical procedure. Its rise in the blood can also precede pain, fever, or other clinical
indicators. The level of CRP can jump a thousand-fold in response to inflammation and
can be valuable in monitoring disease activity.
The Test
How is it used?
The CRP test is useful in assessing patients with:
• Inflammatory bowel disease
• Some forms of arthritis
• Autoimmune diseases
• Pelvic inflammatory disease (PID)
CRP may be used to screen apparently healthy people for the following conditions.
However, in these cases, the more sensitive test hs-CRP will be ordered:
• Coronary heart disease (CHD)
• Cardiovascular disease
While the CRP test is not specific enough to diagnose a particular disease, it does serve as
a general marker for infection and inflammation, thus alerting medical professionals that
further testing and treatment may be necessary.
When is it ordered?
Because CRP increases in severe cases of inflammation, the test is ordered when acute
inflammation is a risk (such as from an infection after surgery) or suspected based on
patient symptoms. It is also ordered to help evaluate conditions such as rheumatoid
arthritis and lupus and is often repeated to determine whether treatment is effective. This is
particularly useful for inflammation problems since CRP levels drop as inflammation
subsides.
CRP also is used to monitor wound healing and to monitor patients who have surgical cuts
(incisions), organ transplants, or burns as an early detection system for possible infections.
A high or increasing amount of CRP in your blood suggests that you have an acute
infection or inflammation.
If the CRP level in your blood drops, it means that you are getting better and inflammation
is being reduced.
69
CRP levels can be elevated in the later stages of pregnancy as well as with use of birth
control pills or hormone replacement therapy (i.e., estrogen). Higher levels of CRP have
also been observed in the obese.
Another test to monitor inflammation is called the erythrocyte sedimentation rate (ESR).
Both tests are elevated in the presence of inflammation; however, CRP appears and then
disappears sooner than changes in the ESR. Thus, your CRP level may fall to normal if
you have been treated successfully, such as for a flare-up of arthritis, but your ESR may
still be abnormal for a while longer.
Common Questions
1. What are chronic inflammatory diseases?
"Chronic inflammatory diseases" is a non-specific term used to characterize long-lasting
or frequently recurring bouts of inflammation as associated with a more specific disease.
This can be caused by a number of different pathological conditions such as arthritis,
lupus, or inflammatory bowel disease (Crohn’s disease).
2. What is the difference between regular CRP and hs-CRP tests?
Both tests measure the same molecule in the blood. The high sensitivity CRP (hs-CRP)
test measures very small amounts of CRP in the blood and is ordered most frequently for
seemingly healthy people to assess their potential risk for heart problems. It measures CRP
in the range from 0.5 to 10 mg/L. The regular CRP test is ordered for patients at risk for
infections or chronic inflammatory diseases (see Question #1). It measures CRP in the
range from 10 to 1000 mg/L.
ASO
Also known as: ASLO
Formal name: Antistreptolysin O titer
Related tests: Strep throat, Anti-DNase-B
Why Get Tested?
To help determine whether a person has had a recent Group A streptococcal infection; to
help diagnose post-streptococcal sequelae of rheumatic fever and glomerulonephritis
When to Get Tested?
When someone has a fever, chest pain, fatigue, shortness of breath, edema, or other
symptoms associated with rheumatic fever or glomerulonephritis, especially when a
person recently had a sore throat but no rapid test or culture was done to confirm a Group
A streptococcal infection
Sample Required?
None
This test measures the amount of antistreptolysin O (ASO) in the blood. ASO is an
antibody targeted against streptolysin O, a toxin produced by Group A streptococcus
70
bacteria. ASO and anti-DNase B are the most common of several antibodies that are
produced by the body's immune system in response to a Group A streptococcal infection.
Group A streptococcus (Streptococcus pyogenes), is the bacterium responsible for causing
strep throat. In most cases, strep infections are identified, treated with antibiotics, and the
infections resolve. When a strep infection does not cause identifiable symptoms, goes
untreated, or is treated ineffectively, however, post-streptococcal complications (sequelae),
namely rheumatic fever and glomerulonephritis, can sometimes develop, especially in
young children. These secondary conditions have become much less prevalent in the U.S.
because of routine strep testing, but they still do occur. They cause symptoms such as
fever, fatigue, shortness of breath, heart palpitations, decreased urine output, and bloody
urine. They can damage the heart and/or cause acute kidney dysfunction, leg swelling
(edema), and high blood pressure (hypertension). Because these symptoms may also be
seen with other conditions, the ASO test can be used to help determine if they are due to a
recent Group A strep infection.
For more information on rheumatic fever and glomerulonephritis, see the Links tab.
The Test
How is it used?
The ASO test is primarily ordered by itself or along with an anti-DNase B to help
determine whether a person has had a recent streptococcal infection. In most cases, strep
infections are identified and treated with antibiotics and the infections resolve. In cases
where they do not cause identifiable symptoms and/or go untreated, however, post-
streptococcal complications (sequelae), namely rheumatic fever and glomerulonephritis,
can develop in some patients, especially young children. The test, therefore, is ordered if a
person presents with symptoms suggesting rheumatic fever or glomerulonephritis and has
had a recent history of sore throat or a confirmed streptococcal infection. Since the
incidence of post-streptococcal complications has dropped in the U.S., so has the use of
the ASO test.
When is it ordered?
The ASO test is ordered when a person has symptoms that the doctor suspects may be due
to an illness caused by a previous streptococcal infection. It is ordered when the symptoms
emerge, usually in the weeks following a sore throat or skin infection. The test may be
ordered twice over a period of 10-14 days to determine if the antibody level is rising,
falling, or remaining the same.
Some symptoms of rheumatic fever may include:
• Fever
• Joint swelling and pain in more than one joint, especially in the ankles, knees,
elbows and wrists, sometimes moving from one joint to another
• Small, painless nodules under the skin
• Rapid, jerky movements (Sydenham's chorea)
• Skin rash
• Sometimes the heart can become inflamed (carditis); this may not produce any
symptoms but also may lead to shortness of breath, heart palpitations, or chest pain
Some symptoms of glomerulonephritis may include:
71
• Fatigue, decreased energy
• Decreased urine output
• Bloody urine
• Rash
• Joint pain
• Swelling (edema)
However, these symptoms can be seen in other conditions.
The test may be performed twice, with samples collected about two weeks apart, for acute
and convalescent ASO titers. This is done to determine if the antibody level is rising,
falling, or remaining the same.
ASO antibodies are produced about a week to a month after an initial strep infection. ASO
levels peak at about 4 to 6 weeks after the illness and then taper off but may remain at
detectible levels for several months after the strep infection has resolved.
If the test is negative or if ASO is present in very low concentrations, then the person
tested most likely has not had a recent strep infection. This is especially true if a sample
taken 10 to 14 days later is also negative or low level and if an anti-DNase B test is also
negative. A small percentage of those with a post-streptococcal complication will not have
an elevated ASO.
If the ASO level is high or is rising, then it is likely that a recent strep infection has
occurred. ASO levels that are initially high and then decline suggest that an infection has
occurred and may be resolving.
The ASO test does not predict if complications will occur following a streptococcal
infection, nor do they predict the type or severity of the disease. If symptoms of rheumatic
fever or glomerulonephritis are present, an elevated ASO level may be used to help
confirm the diagnosis.
Some antibiotics and corticosteroids may decrease ASO antibody levels.
Common Questions
1. Can ASO be used to diagnose strep throat?
A throat culture or a rapid strep test is the best method to diagnose streptococcal
pharyngitis. It is important that strep throat be promptly identified and treated to avoid
complications and to avoid passing the infection on to others. Since detectible ASO levels
do not appear for at least a week, they are not used to diagnose an acute infection.
2. If I am diagnosed with strep, will an ASO always be performed?
No. In general, the ASO test is only performed when someone has symptoms suggesting
that a post-streptococcal complication may have developed and no culture was done to
confirm a previous infection with this bacterium. Most people do not experience these
complications, so the ASO test is not routinely done.
72
Antibody Tests
What are antibody tests?
Antibody tests involve analyzing a patient’s sample (usually blood) for the presence or
absence of a particular antibody (qualitative) or for the amount of antibody that is present
(quantitative).
Antibodies are part of the body's immune system. They are immunoglobulin proteins that
help protect people against microscopic invaders such as viruses, bacteria, chemicals, or
toxins. Each antibody that is produced is unique. It is created to recognize a specific
structure on an invading foreign cell or particle. The specific structure that is recognized is
called an antigen. Antibodies attach to the antigens, creating antigen-antibody complexes
(immune complexes) that serve as signals for the rest of the immune system to destroy the
cell or particle.
There are five different classes of immunoglobulins (IgM, IgG, IgE, IgA, and IgD). The
three most frequently measured are IgM, IgG, and IgE. IgM and IgG antibodies work
together to produce short-term and long-term protection against infection. IgE antibodies
are primarily associated with allergies.
The first time someone is exposed to a foreign substance, like a virus or bacterium, it may
take the immune system up to two weeks to make an antibody blueprint and to produce
enough of a specific antibody to fight the infection. This initial response consists primarily
of IgM antibodies. Several weeks later, usually after the immediate threat has passed and
the infection has resolved, the body creates IgG antibodies. It remembers the blueprint for
fighting this microorganism and maintains a small supply of antibodies (a mixture of both
IgM and IgG). The next time the body is exposed to the same foreign substance, it will
respond much more strongly and quickly, to provide primarily IgG antibody protection.
Vaccines are designed to trigger production of antibodies prior to exposure to a potentially
infective microorganism. Vaccines use either a weakened version of the microorganism
(one that cannot cause infection) or an isolated protein that mimics an antigen structure on
the surface of the microorganism. Thus, the vaccine provides a relatively safe initial
exposure to generate the blueprint for future protection. Vaccines generate an initial
immune response to create IgM antibodies and a secondary response that provides a
supply of IgG antibodies. The antibodies generated by the vaccine provide long-term,
rapid-response protection (termed immunity). Additional booster shots are sometimes
given after the first vaccination to raise the concentration of antibodies in the blood to a
level considered to be sufficiently protective (provide adequate immunity).
Appropriate antibody production and targeting depends on the body's ability to distinguish
between itself and foreign substances and to correctly identify foreign substances that
represent threats. Normally, a person's immune system learns to identify and ignore the
antigens that are present on the person’s own organs, tissues, and cells. Sometimes,
however, it will mistakenly identify a part of the person’s own body as foreign and
produce autoantibodies. These autoantibodies trigger an inflammatory reaction that
attempts to destroy the body’s own tissue in the same way it would try to destroy a foreign
invader. An autoimmune response can affect a single organ (like the thyroid) or be
systemic, affecting many tissues or organs. These autoantibody-induced responses result
in conditions termed autoimmune disorders or autoimmune diseases.
73
Antibodies may also trigger immune responses to blood transfusions or organ
transplantations. Although patients are given blood or organs that most closely match their
own blood or organs to minimize the chance of an immune response, matches are not
always perfect. Antigens in donated blood that is given during a blood transfusion may
stimulate an immune reaction termed a transfusion reaction. All patients receiving donor
blood must be watched carefully for symptoms of transfusion reaction. Antigens on
transplanted body organs may stimulate an immune response that can lead to organ
rejection. Transplant patients are treated with drugs to suppress their immune systems to
avoid rejection of the transplanted organ.
Sometimes a person's immune system may respond to foreign substances that represent no
threat and typically do not generate immune reactions in most people. Such responses are
termed allergies (or hypersensitivities) and involve generation of IgE antibodies. The
foreign substances that trigger allergic reactions include foods, pollens, molds, and animal
dander. There are many different types of allergies, and allergic reactions may vary from
mild irritations to severe life-threatening responses.
Why are antibody tests done?
The main reasons that antibody tests are done or antibody concentrations are measured are
to:
• Document exposure to an infectious or foreign agent
• Evaluate protection level (immune status) against a particular microorganism
• Diagnose an autoimmune condition
• Diagnose the reason for a transfusion reaction or a rejection of a transplanted organ
• Diagnose an allergy
• Monitor the course of an infection or autoimmune process
There is not a single "umbrella" test that will measure all of a person’s various antibody
levels; antibodies are as individual as the diseases they target. Antibody tests are ordered
singly or in combinations, depending on a patient’s symptoms and on what information
the doctor is trying to gather. If the doctor suspects a current infection, two samples (called
acute and convalescent samples) may be collected (a few weeks apart) to look for changes
in antibody levels.
Some antibody testing focuses on specific IgM, IgG, IgA and/or IgE tests. IgG and IgM
tests are used primarily for diagnosis and monitoring of infectious diseases or for
determination of immune status. IgE testing is used primarily to identify and monitor
allergies to specific substances. IgA testing is often used in allergy testing and in the
diagnosis of celiac disease.
What do the test results mean?
Antibody tests usually involve mixing the patient’s sample with a known antigen, the
substance that the antibody is directed against or produced in response to, and seeing if a
reaction takes place. If an antibody is present and binds to the known antigen, the
formation of the antibody-antigen complex can be measured.
There really isn't a "normal" antibody concentration since people produce antibodies at
different rates. Patients with compromised immune systems may not be able to respond
normally, producing fewer antibodies and/or responding more slowly to antigen exposure.
74
The meaning of a particular test result depends on the patient’s symptoms and the specific
circumstances that led to testing.
Results may be reported in a qualitative manner as "detected" or "not-detected" in the case
of antibodies to agents causing chronic infections (such as HIV), where any amount of
antibody is considered meaningful. They may be reported out as "greater than" a particular
cutoff level if immunity is being checked (above that level - which varies depending on
the microorganism involved - a person is usually considered to be protected), or as
"immune" or "non-immune" (meaning that the person does or does not have sufficient
antibodies to ward off infection). Results may also be reported as a number representing a
concentration.
Detection of IgM antibodies tends to indicate a recent initial exposure to an antigen
whereas detection of total or IgG antibodies indicates exposure some time ago.
Antibody titers are sometimes used to evaluate how significant a positive antibody level is.
These titers involve diluting the sample – creating and testing serial (increasing) dilutions.
The highest dilution that is still positive is reported out as a "1 to dilution rate" ratio (for
instance 1:40 or 1:320, etc.). This is still used to report out some antibody levels,
especially in the case of autoimmune conditions. "Antibody titer" is a term that is also
sometimes used generically to refer to antibody concentrations.)
High levels of individual IgE antibodies may help diagnose an allergy, but they do not
necessarily correlate to the severity of the symptoms that a patient may be experiencing. A
patient who has been avoiding an offending substance, such as peanuts, may have low to
moderate concentrations of IgE peanut antibodies when tested. However, with subsequent
exposure, the person’s peanut antibody concentrations would rise again.
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Glucose

GLUCOSE LEVEL INDICATION

Oral Glucose Tolerance Test (OGTT)

GLUCOSE LEVEL INDICATION

Gestational Diabetes Screening: Glucose Challenge Test

Sample drawn 1 hour after a 50-gram glucose drink.

GLUCOSE LEVEL INDICATION

Gestational Diabetes Diagnostic: OGTT

TIME OF SAMPLE COLLECTION TARGET LEVEL

3. I heard women don’t get gout. Is that true?

Total Protein and A/G Ratio

Is there anything else I should know?

What is being tested?

2. Are there other tests used to follow the disease?

When to Get Tested?

3. What are the treatments for HIV/AIDS?

Why Get Tested?

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