Introductory preface for special series Investigative Algorithms in Laboratory Medicine II: Focus on Bone and Liver

When laboratory automated analysers were first being used, computers were considerably more expensive, therefore tests were run in panels as it was cost prohibitive to allow users to select the individual tests they required. This practice remains widespread meaning that, when asking for liver or bone profiles for example, one can be faced with abnormalities of tests you were not expecting for a test that may not have been specifically indicated. In a setting of easy access to a plethora of guidelines and trial data it can then be surprisingly difficult to find a simple answer to the approach to an unexpected abnormal laboratory test result. Therefore, and following on from the success of the first series, we are pleased to provide further investigative algorithms with a focus on liver and bone tests (1-7).

The dangers of overdiagnosis are increasingly recognised and the aim here is to provide simple approaches to prevent wasted resources and unnecessary patient anxiety (8). These algorithms concentrate only on the laboratory aspect of patient management.

Liver enzymes are a good example where profile results may lead to over investigation. For example, monitoring of liver function is often performed in people on medications who are otherwise well or well-treated and asymptomatic from their chronic disease. Although some of this may be driven by drug license requirements stopping testing or doing limited liver tests, e.g., ALT only, is not only safe but reduces work caused by non-significant transient test abnormalities (9). Lactate dehydrogenase is present in all tissues effectively and therefore elevations are non-specific to the origin organ, which reduces its value as a screening tool (2).

Abnormalities of calcium can be caused by serious pathology, e.g., malignancy, or can have serious consequences, e.g., nephrotoxicity with hypercalcaemia. There are data to support that the initial abnormalities can be missed and patients harmed due to the delay and misdiagnosis (10). Therefore, an initial approach to hyper and hypocalcaemia should be familiar to all clinicians reviewing results. An algorithm on phosphate abnormalities is still in press and will join the article series imminently.

It is hoped that any user, with any level of experience, will find these critically reviewed approaches helpful. These articles do not replace clinical guidelines but provide a suggested systematic approach to unexpected biochemical abnormalities.

Kate E. Shipman

Acknowledgments

We would like to thank Professor Neil Gittoes, Mr. Kade Flowers and Dr. Alexa Shipman for their significant involvement in preparing the papers that make up the following series of articles.

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Laboratory and Precision Medicine for the series “Investigative Algorithms in Laboratory Medicine II: Focus on Bone and Liver”. The article did not undergo external peer review.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://jlpm.amegroups.org/article/view/10.21037/jlpm-24-51/coif). The series “Investigative Algorithms in Laboratory Medicine II: Focus on Bone and Liver” was commissioned by the editorial office without any funding or sponsorship. K.E.S. served as an unpaid Guest Editor of the series and serves as the unpaid editorial board member of the Journal of Laboratory and Precision Medicine from September 2024 to December 2026. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Shipman KE, Shipman AR. Introductory preface for special series: investigative algorithms in laboratory medicine—electrolytes and acid/base. J Lab Precis Med 2022;7:8. [Crossref]
2. Shipman AR, Bahrani S, Shipman KE. Investigative algorithms for disorders affecting plasma lactate dehydrogenase: a narrative review. J Lab Precis Med 2024;9:15. [Crossref]
3. Flowers KC, Shipman KE, Shipman AR, et al. Investigative algorithms for disorders causing hypercalcaemia and hypocalcaemia: a narrative review. J Lab Precis Med 2024;9:27. [Crossref]
4. Duvall LE, Shipman AR, Shipman KE. Investigative algorithms for disorders affecting plasma proteins with a focus on albumin and the calculated globulin fraction: a narrative review. J Lab Precis Med 2023;8:19. [Crossref]
5. Verran C, Shipman AR, Shipman KE. Investigative algorithms for disorders affecting plasma bilirubin: a narrative review. J Lab Precis Med 2024;9:6. [Crossref]
6. Shipman AR, Shipman KE. Investigative algorithms for disorders affecting plasma transaminases (aspartate transaminase and alanine transaminase)—a narrative review. J Lab Precis Med 2024;9:14. [Crossref]
7. Irving M, Shipman AR, Shipman KE. Investigative algorithms for disorders affecting human plasma alkaline phosphatase: a narrative review. J Lab Precis Med 2024;9:7. [Crossref]
8. Kale MS, Korenstein D. Overdiagnosis in primary care: framing the problem and finding solutions. BMJ 2018;362:k2820. [Crossref] [PubMed]
9. Homer K, Robson J, Solaiman S, et al. Reducing liver function tests for statin monitoring: an observational comparison of two clinical commissioning groups. Br J Gen Pract 2017;67:e194-200. [Crossref] [PubMed]
10. Lorenz FJ, Beauchamp-Perez F, Manni A, et al. Analysis of Time to Diagnosis and Outcomes Among Adults With Primary Hyperparathyroidism. JAMA Netw Open 2022;5:e2248332. [Crossref] [PubMed]