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Diagnosis and tests

Heart, liver, kidneys

Before leukemia treatment starts and throughout it, doctors look not only at the blood cells but also at the heart, liver and kidneys. These three organs carry, process and clear medicines. This topic explains which tests are done and why they matter.

Last updated: ~5 min read
Inside a translucent human silhouette on a dark navy background, three organs glow softly — the heart, the liver and both kidneys — each with a small glowing check mark beside it; no face.
Figure 1.Concept: three organs are checked before treatment.

01Short answer

After a leukemia diagnosis and during treatment, organ function is checked regularly. For the heart, an ECG (electrocardiogram) shows the rhythm and an echocardiogram shows how strongly the heart pumps; this is especially important before drugs that can affect the heart, such as anthracyclines. For the liver, a blood chemistry panel measures ALT, AST, bilirubin, alkaline phosphatase and albumin; many drugs are processed in the liver. For the kidneys, creatinine, eGFR (filtration rate), urea and electrolytes (potassium, sodium, calcium, phosphate) are checked; many drugs leave the body through the kidneys. In addition, uric acid and LDH help track the breakdown of leukemia cells (the risk of tumour lysis syndrome), and clotting tests (PT/INR, fibrinogen, D-dimer) help assess the risk of bleeding and clots. The results shape the choice of drug, the dose and extra protective measures; go through them with your doctor.

02Simple explanation

Medicines travel through the body: the heart carries them in the blood, the liver processes them and the kidneys clear them.

If one of these organs is working less well, a medicine can stay in the body longer or cause more side effects.

So the doctor first “checks the road”: an ECG, a heart ultrasound and a blood chemistry test.

When treatment starts, leukemia cells break down quickly and a lot of salts and uric acid can enter the blood. Fluids and medicines are given to protect the kidneys.

The tests are repeated throughout treatment so that changes are seen in time.

03Scientific explanation

Heart. The NHS explains that an echocardiogram uses ultrasound to show the structure of the heart and how well it pumps. Anthracyclines (daunorubicin, idarubicin, doxorubicin) can affect the heart muscle depending on the total dose received, so the heart’s starting condition is recorded before treatment. An ECG shows the rhythm and the QT interval; arsenic trioxide, used in APL, and some other drugs can prolong the QT, so the ECG and potassium and magnesium levels are monitored.

Liver. According to MedlinePlus, liver function tests include ALT, AST, alkaline phosphatase, bilirubin and albumin. Raised enzymes can reflect a drug effect, an infection (for example, reactivation of hepatitis B) or liver involvement by leukemia cells. With some drugs, such as asparaginase, liver results receive particular attention.

Kidneys. Creatinine and eGFR reflect how well the kidneys filter. Some drugs, such as methotrexate, are mainly cleared by the kidneys, and their dose or monitoring is adjusted to kidney function. The kidneys are also checked before contrast scans and some antibiotics.

Tumour lysis and clotting. The NCI describes tumour lysis syndrome as a rise in blood potassium, phosphate and uric acid caused by the breakdown of many cancer cells in a short time; it can harm the kidneys and disturb the heart rhythm. The risk is higher with a very high white cell count and fast-growing leukemias, so in the first days of treatment blood is tested often, sometimes several times a day. LDH is a general marker of cell breakdown. Clotting tests are especially important in APL and when DIC (disseminated intravascular coagulation) is suspected.

04What happens in the body?

How is the heart checked?

An ECG takes a few minutes: sticky electrodes are placed on the chest, arms and legs. An echocardiogram is an ultrasound of the heart; it is painless and takes 20–40 minutes. The report gives the “ejection fraction” — the share of blood the heart pushes out with each beat. Some centres use a nuclear heart scan instead.

A translucent heart model with a soft red glow on a dark navy background; the outflow of blood is shown with an arrow, with ultrasound waves and a calm measuring scale beside it; no people.
Figure 2.An echocardiogram measures how strongly the heart pumps.

How is the liver checked?

With an ordinary blood sample from a vein. A chemistry panel measures liver enzymes, bilirubin and albumin at once. If needed, a liver ultrasound and hepatitis B and C tests are done.

How are the kidneys checked?

Creatinine, urea, eGFR and electrolytes are measured from the same blood sample. Sometimes a urine test or a 24-hour urine collection is needed. During treatment, the amount of fluid you take in and pass may be recorded.

Two translucent kidneys on a dark navy background; small glowing filters inside clean the blood, and beside them coloured crystals representing potassium and phosphate sit in balance on a scale.
Figure 3.The kidneys filter the blood and keep salts in balance.

How is tumour lysis prevented?

Depending on the risk, the team plans IV fluids, medicines that lower uric acid and frequent blood tests. This is a normal, expected part of treatment. Tell the team straight away if you are passing less urine or have muscle cramps or palpitations.

If a result is outside the normal range

It does not necessarily mean treatment stops. Often the dose is changed, another drug is chosen, protective measures are taken or a cardiologist, liver specialist or kidney specialist is involved. The decision is made by your treating doctor.

05A medicine’s journey: carrying, processing, clearing

Each stage has its own test.

Heart — ECG and echocardiogram: rhythm and strength.1HeartECG and echocardiogram: rhythm and strength.
Liver — ALT, AST, bilirubin: how the drug is processed.2LiverALT, AST, bilirubin: how the drug is processed.
Kidneys — Creatinine and eGFR: how the drug is cleared.3KidneysCreatinine and eGFR: how the drug is cleared.
Lysis and clotting — Potassium, phosphate, uric acid, PT/INR.4Lysis and clottingPotassium, phosphate, uric acid, PT/INR.
A safe doseA choice that fits your organs.
The heart protectedIts starting condition is recorded.
Early warningChanges are seen early.

06Key organ tests

OrganTestWhat it showsWhen it matters most
HeartECGRhythm, QT intervalDrugs that affect QT, electrolyte problems
HeartEchocardiogramPumping strengthBefore and during anthracyclines
LiverALT, AST, bilirubin, albuminLiver cells and functionDrugs processed by the liver, hepatitis
KidneysCreatinine, eGFR, ureaFiltering capacityDrugs cleared by the kidneys, contrast
MetabolismPotassium, phosphate, calcium, uric acid, LDHCell breakdownThe first days of treatment
ClottingPT/INR, fibrinogen, D-dimerRisk of bleeding and clotsAPL, suspected DIC, asparaginase

* Normal ranges vary between laboratories. Discuss your own numbers with your doctor.

07Key terms

ECG
A recording of the heart’s electrical activity.
Echocardiogram
An ultrasound scan of the heart.
Ejection fraction
The share of blood the heart pumps out with each beat.
QT interval
The part of the ECG that reflects the heart’s electrical recovery.
ALT, AST
Enzymes found in liver cells.
Creatinine
A waste product of muscle; it reflects kidney function.
eGFR
The estimated filtration rate of the kidneys.
Tumour lysis syndrome
A rise in blood salts and uric acid caused by the rapid breakdown of cancer cells.

08Key points

  • The heart, liver and kidneys shape a medicine’s journey.
  • Heart strength is measured before anthracyclines.
  • With some drugs, the QT is monitored on the ECG.
  • Liver and kidney results can affect the dose.
  • In the first days, blood is tested often for tumour lysis.
  • Tell your doctor about all medicines and supplements.
  • A result outside the range does not always mean treatment stops.

09Frequently asked questions

Why is blood taken every day?

Early in treatment, blood cells, electrolytes and organ results can change quickly. Frequent tests make it possible to spot a problem early and correct it in time. With a central line, extra needles are not needed.

My heart is healthy. Do I still need an echocardiogram?

Yes, often you do. It records the starting condition before treatment so there is something to compare with if changes appear later.

My liver enzymes are raised. Does this mean the leukemia has spread?

Not necessarily. The cause is more often medicines, infections or transfusions. Your doctor finds the cause with further tests.

Should I drink lots of water to prevent tumour lysis?

The amount of fluid is set by your doctor; it is often given through a drip. Check with the team before drinking large amounts on your own, especially if you have heart or kidney problems.

Are these tests different for children?

The principles are the same, but normal ranges depend on age. Children also have their heart checked before anthracyclines, and follow-up can continue for years after treatment.

10Questions for your doctor

Take these questions to your appointment. The ones you save are collected on the “My questions” page and stay on this device only.

  1. Why is blood taken every day?

  2. My heart is healthy. Do I still need an echocardiogram?

  3. My liver enzymes are raised. Does this mean the leukemia has spread?

  4. Should I drink lots of water to prevent tumour lysis?

  5. Are these tests different for children?

My questions

12Sources

  1. American Cancer Society. Tests for Acute Myeloid Leukemia (AML)
  2. American Cancer Society. Tests for Acute Lymphocytic Leukemia (ALL)
  3. MedlinePlus (U.S. National Library of Medicine). Comprehensive Metabolic Panel (CMP)
  4. MedlinePlus (U.S. National Library of Medicine). Liver Function Tests
  5. MedlinePlus (U.S. National Library of Medicine). Creatinine Test
  6. MedlinePlus (U.S. National Library of Medicine). Glomerular Filtration Rate (GFR) Test
  7. MedlinePlus (U.S. National Library of Medicine). Electrolyte Panel
  8. MedlinePlus (U.S. National Library of Medicine). Uric Acid Test
  9. MedlinePlus (U.S. National Library of Medicine). Lactate Dehydrogenase (LDH) Test
  10. MedlinePlus (U.S. National Library of Medicine). Prothrombin Time Test and INR (PT/INR)
  11. NHS. Echocardiogram
  12. NHS. Electrocardiogram (ECG)
  13. National Cancer Institute (NCI). Tumor lysis syndrome — NCI Dictionary of Cancer Terms
Medical disclaimerThis information is for educational purposes only and does not replace medical advice.
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