Advanced Biomarker Patterns: Reading Panels as Systems
Level 4, Advanced
In brief
Individual test results gain meaning when read together as patterns. Recurring patterns include the insulin resistance pattern, the alcohol pattern, the hypothyroid pattern, the malabsorption pattern, the inflammation pattern, the iron overload pattern and the kidney pattern. Patterns suggest hypotheses rather than diagnoses, must be confirmed through history and targeted testing, and can mislead when a single abnormal value is over interpreted.
A standard panel of blood tests, a blood count, kidney and liver function, lipids, glucose, thyroid function and a few others, contains more information than any single result suggests. Physiology does not respect the boundaries between test groups. Insulin resistance affects liver enzymes, lipids, uric acid and ferritin. Alcohol affects the blood count, liver enzymes and lipids. Malabsorption affects iron, vitamins, albumin and cholesterol. Reading panels as systems means looking across results for recognisable patterns. Earlier articles examined individual panels; this article brings them together.
Principles of pattern reading
- Look across groups. Scan the whole panel before focusing on individual results.
- Notice values within range but at the edges, especially when several point in the same direction.
- Compare with previous results. Trends matter more than single values.
- Match the pattern to the history. A pattern suggests a hypothesis; the history supports or refutes it.
- Confirm with targeted tests rather than broad panels.
- Beware of over interpretation. One mildly abnormal value is often noise.
Common patterns
| Pattern | Typical findings | Confirm with |
|---|---|---|
| Insulin resistance | Raised triglycerides, low HDL, fasting glucose or HbA1c at upper range, ALT higher than AST, raised GGT, raised uric acid, mildly raised ferritin, sometimes mildly raised white cell count | Waist, blood pressure, fasting insulin, liver imaging and FIB 4 |
| Alcohol | Raised MCV, raised GGT, AST higher than ALT, raised triglycerides, raised uric acid, sometimes low platelets and raised HDL | Careful alcohol history; liver assessment |
| Hypothyroid | Raised LDL, raised creatine kinase, sometimes low sodium, mild macrocytosis or anaemia | TSH and free T4 |
| Malabsorption | Low ferritin, low folate or B12, low vitamin D, low albumin, low cholesterol, sometimes raised ALT and low calcium or magnesium | Coeliac serology, faecal elastase, further gut assessment |
| Inflammation | Raised CRP and ESR, raised platelets, raised ferritin, low albumin, low haemoglobin with low iron and transferrin saturation | History and examination for the source |
| Iron overload | Raised transferrin saturation, raised ferritin, sometimes raised ALT | Repeat fasting transferrin saturation, HFE genotyping |
| Kidney impairment | Reduced eGFR, raised creatinine, raised potassium, low bicarbonate, raised phosphate, anaemia | Urine albumin to creatinine ratio, repeat eGFR, kidney imaging where indicated |
| Cortisol excess clues | Raised glucose, low potassium, raised neutrophils, low lymphocytes and eosinophils | Screening tests for Cushing syndrome if clinical features suggest it; consider steroid use |
| Dehydration | Raised urea relative to creatinine, raised haemoglobin and albumin | Clinical assessment; repeat when hydrated |
| Haemolysis | Raised bilirubin, raised LDH, raised reticulocytes, low haptoglobin, anaemia | Medical assessment |
Markers often overlooked
Urine albumin to creatinine ratio
Raised urine albumin is an early marker of kidney damage and a strong predictor of cardiovascular risk, particularly in diabetes and hypertension. It is often omitted from routine panels but recommended in these conditions.
Uric acid
Raised uric acid is associated with insulin resistance, fructose and alcohol intake, kidney function and gout, and is part of the metabolic pattern.
GGT
A sensitive but non specific marker that rises with alcohol, fatty liver and enzyme inducing medicines, and is associated with cardiometabolic risk.
Creatine kinase
Raised by exercise, muscle injury, hypothyroidism and statin related muscle effects; helpful in interpreting a raised AST.
Albumin
Reflects nutrition, inflammation, liver function and protein loss; low albumin affects the interpretation of calcium, zinc and other bound substances.
When patterns mislead
- Overlapping patterns: a patient may have insulin resistance and drink alcohol, with results reflecting both.
- Medicines: many alter results, such as statins lowering LDL, diuretics altering electrolytes and uric acid, and metformin affecting B12.
- Acute illness: temporarily alters many markers.
- Laboratory variation: reference ranges and methods differ.
- Population differences: for example, lower neutrophil counts in some ancestries.
- Chance: in a large panel, some results will fall outside the range randomly.
A worked panel
A 49 year old man attends with fatigue. His results include:
| Test | Result | Comment |
|---|---|---|
| MCV | 101 fL, slightly raised | Macrocytosis |
| Platelets | Low normal | |
| GGT | 3 times upper limit | |
| AST and ALT | AST 64, ALT 30 | AST to ALT ratio above 2 |
| Triglycerides | 2.8 mmol/L | |
| HDL | 1.8 mmol/L | Higher than expected |
| Uric acid | Raised | |
| HbA1c | 38 mmol/mol | Normal |
| B12 and folate | Normal | |
| TSH | Normal |
No single result is alarming, but together they form a classic alcohol pattern. The practitioner asks about alcohol carefully and without judgement; he drinks around 40 units a week. His doctor arranges liver fibrosis assessment. With support, he reduces his drinking substantially. 3 months later his MCV, GGT, AST, triglycerides and uric acid have all improved, and his fatigue is better.
Systems, not numbers
Pattern reading turns a list of results into a picture of physiology. It helps practitioners notice what individual values hide, ask the right questions and order the right confirmatory tests, while remaining cautious about drawing conclusions from any single result.
Questions about biomarker patterns
Why read results as patterns?
What does an alcohol pattern look like?
Can patterns diagnose conditions?
References
- Newsome PN, Cramb R, Davison SM, et al. Guidelines on the management of abnormal liver blood tests. Gut. 2018;67(1).
- Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney International. 2024;105(4S).
- Alberti KGMM, Eckel RH, Grundy SM, et al. Harmonizing the metabolic syndrome: a joint interim statement. Circulation. 2009;120(16).
- Kaferle J, Strzoda CE. Evaluation of macrocytosis. American Family Physician. 2009;79(3).
Continue your learning
Reading laboratory panels as whole systems
Reading panels as connected systems, rather than lists of numbers, is practised throughout IIFM’s 6 month Functional Medicine and Clinical Nutrition program in case based sessions.
This article is for the education of healthcare professionals. It is not a substitute for individual medical advice, diagnosis or treatment, and does not change any practitioner’s scope of practice. Regulation and guidelines differ between countries.