Introduction

Patients have liver function tests checked for a variety of reasons both in the community and in hospital settings. Liver tests can be acutely or chronically deranged and can be abnormal for a number of reasons. A ‘liver screen’ is commonly requested to investigate abnormal liver functions tests. The screen can be modified depending on the age of the patient and whether acute or chronic liver disease is suspected.

A careful history is vital. Salient points in the history should be:

Personal or family history of liver disease
Personal or family history of autoimmune disease
Alcohol – pattern of consumption, including volume and duration
Risk factors for viral hepatitis (injecting drug use, tattoos, blood transfusions and lived or had medical treatment in a country where Hepatitis C is common)
Medication history for the past 6 months including antibiotics, over the counter and herbal remedies and recreational drugs

A thorough examination should include

Signs of chronic liver disease
Evidence of decompensation (jaundice, ascites, hepatic encephalopathy)

The following tests should be included in a non-invasive liver screen:

Hepatitis B surface antigen and core antibody
Hepatitis C antibody
Liver autoantibodies – anti-mitochondrial antibody (AMA), anti-nuclear antibody (ANA), anti-smooth muscle antibody (ASMA)
Immunoglobulins
Ferritin and transferrin saturations
Alpha-1 antitrypsin
An abdominal ultrasound scan should also form part of the initial liver screen

In patients <40 years old – caeruloplasmin should be checked

If an acute hepatitis is suspected then Hepatitis A IgM, Hepatitis E IgM, CMV IgM, EBV IgM and HSV IgM should also be checked. If the patient is immunosuppressed then Hepatitis E PCR should be checked rather than the IgM.

Hepatitis B

Overview

Hepatitis B is a DNA virus that is blood borne, spread through contact with infected blood and/or bodily fluids. A vaccine is available to protect against infection. The risk of Hepatitis B infection progressing to chronic Hepatitis B depends on when the infection was acquired. Infections acquired at birth or in childhood are far more likely to progress to chronic hepatitis B. The majority of infections acquired in adulthood will be cleared by the patient’s immune system and will not require treatment.

Diagnosis

Hepatitis B surface antigen (HBsAg) – this suggests active infection which could be acute or chronic infection.

Hepatitis B surface antibody (HbsAb) – this will be positive in isolation (other tests will be negative) in someone who has been vaccinated against Hepatitis B. When HbsAb is positive in combination with the core antibody, then this would suggest immunity from previous exposure to the virus.

Hepatitis B core antibody (HbcAb) - this appears during acute infection and persists for life. If positive in isolation it usually suggests resolved past infection. This not usually clinically relevant unless the patient is on immunosuppressive medications or chemotherapy as Hepatitis B can reactivate in this setting. This group of patients do not require referral but should be informed of diagnosis and to be aware if they are offered immunosuppressive medications or chemotherapy.

Acute or chronic? Acute Hepatitis B infection is characterised by the presence of HBsAg and immunoglobulin M (IgM) to the antibody to the core antigen (HBcAg). Chronic Hepatitis B infection is characterised by the persistence of HBsAg for at least 6 months.

Treatment

Treatment is not required for all patients with Hepatitis B. The decision to treat is based on Hepatitis B DNA levels, ALT levels and the severity of liver disease. Treatment aims to suppress viral replication and is usually required long-term. The goal of treatment is to prevent progression of liver disease and reduce the risk of the complications of cirrhosis such as liver cancer.

Referral

Patients with evidence of Hepatitis B (Hepatitis B surface antigen positive) should be referred for assessment, monitoring and consideration of treatment.

Hepatitis B core antibody positive (in isolation) patients do not need referred but need to be told about the diagnosis of past Hepatitis B infection as they need to be aware of the risk of reactivation with immunosuppressive medication. They may require prophylactic treatment if being offered immunosuppressive medication or chemotherapy.

First degree relatives and sexual partners of patients with Hepatitis B should be tested for Hepatitis B and vaccinated if they are negative.

References

EASL 2017 Clinical Practice Guidelines on the management of hepatitis B virus infection. Journal of Hepatology 2017; 67 :370–398

Hepatitis C

Overview

Hepatitis C is an RNA virus which predominantly affects the liver. Not everyone who is infected will develop chronic infection. Approximately 20% of those infected with Hepatitis C will clear the virus spontaneously. The remaining 80% will develop chronic infection and are at risk of liver damage from inflammation, fibrosis, cirrhosis and the development of complications including liver cancer. Treatment aims to clear the virus and therefore prevent progression of liver disease, reduce the complications of cirrhosis including liver cancer and also to prevent onward transmission of Hepatitis C.

Diagnosis

Hepatitis C antibody test determines if there has been any previous exposure to the virus but does not test for active infection. It can take a few months for antibodies to develop so the test may need to be repeated if exposure or potential exposure is recent.

Hepatitis C core antigen is a marker of viral replication and will be positive in patients with acute or chronic hepatitis C infection and can be particularly useful when RNA levels are not available.

Hepatitis C RNA tests for virus circulating in the blood stream and if positive indicates active infection.

Treatment

Treatment is not always required because if the infection is diagnosed acutely, then it may still be cleared by the patient’s own immune system. Treatment is nearly always required for chronic infection and there is highly effective anti-viral treatment for Hepatitis C. Treatment will cure infection in approximately 95% of patients. Treatment is an 8 or 12 week course of tablets. The treatments are very well tolerated by patients with few side effects.

Referral

If Hepatitis C antibody is positive but RNA levels are negative then this indicates that the patient has been exposed to the virus but has either previously been successfully treated or has cleared the virus. This group of patients do not need referred for treatment as they do not have active infection.

A positive Hepatitis C antibody test with either a positive core antigen or detectable RNA (i.e. PCR positive) should be referred for assessment and consideration of treatment.

It is important to remember that reinfection can occurs both in individuals who have spontaneously cleared the virus and in those who have been treated and achieved sustained virological response (SVR). This is particularly relevant if risk behaviours continue.

References

EASL Recommendations on treatment of hepatitis C: Final update of the series. Journal of Hepatology 2020; 73 : 1170–1218

Liver autoantibodies

The three main types of autoimmune liver disease are Primary Biliary Cholangitis (PBC), Autoimmune Hepatitis (AIH) and Primary Sclerosing Cholangitis (PSC). Serum autoantibodies and immunoglobulins are frequently checked as part of the liver screen but are not particularly sensitive or specific. Hypergammaglobulinaemia is frequently observed in patients with chronic liver disease of any cause.

Diagnosis

Anti-mitochondrial antibody (AMA) - this is raised in >95% of patients with Primary Biliary Cholangitis. Can also be found in up to 20% patients with AIH.

Anti-nuclear antibody (ANA) can be raised in a number of autoimmune conditions and is not sensitive or specific to liver disease. It is raised in patients with type 1 autoimmune hepatitis. It can however be present in other forms of autoimmune liver disease (PBC and PSC) and other forms of chronic liver disease.

Anti-smooth muscle antibody (ASMA) is raised in type 1 autoimmune hepatitis but can also be raised in other forms of chronic liver disease.

Extended autoantibodies:

Soluble liver antigen / liver pancreas antigen is positive in 10-30% patients with AIH
Liver kidney microsome-1 antibody (LKM) is associated with type 2 autoimmune hepatitis

IgG - is raised in approximately 85% patients with AIH and is used to guide response to treatment

IgA – this can be raised in both alcohol-related liver disease (ARLD) and non-alcoholic fatty liver disease (NAFLD)

IgM - this is raised in Primary Biliary Cirrhosis

Referral

Patients with abnormal liver function tests and positive autoantibodies or immunoglobulins who are suspected of having autoimmune liver disease should be referred to a gastroenterologist or hepatologist for further assessment.

References

Hirschfield GM, et al. The British Society of Gastroenterology/UK PBC primary biliary cholangitis treatment and management guidelines. Gut 2018;67:1568–1594
Chapman MH, et al. British Society of Gastroenterology and UK-PSC guidelines for the diagnosis and management of primary sclerosing cholangitis. Gut 2019;68:1356–1378.

Ferritin

There are a number of causes of raised serum ferritin which are covered in the haematology module - see this for more.

This section covers hyperferritaemia in the context of liver disease.

Secondary iron overload is seen in a variety of conditions including chronic liver disease of all causes. If ferritin is raised it should prompt checking of transferrin saturations. This will help differentiate between hereditary haemochromatosis and the secondary iron overload seen in chronic liver disease.

Genetic haemochromatosis

Genetic Haemochromatosis (GH) is an autosomal recessive genetic condition characterised by excessive intestinal absorption of iron resulting in iron overload. In Northern Europe, 95% of patients with GH will have mutations in the HFE gene.

The most common mutation associated with GH is the C282Y variant of the HFE gene and clinical signs of iron overload may be seen when two copies of the mutation are present (C282Y homozygotes). A second mutation of the HFE gene is H63D. This is not usually associated with iron accumulation. When a single copy of the H63D mutation is inherited along with a single copy of C282Y this is called a compound heterozygote. In Northern Europe, 10% of people are carriers of one of the two significant mutations: C282Y and H63D, with 1 in 200 being homozygous for the C282Y mutation.

C282Y homozygotes are most at risk of iron overload and account for >90% of GH clinical cases. However not everyone who is C282Y homozygous will develop iron overload or the clinical syndrome of iron overload. Compound heterozygotes (C282Y/H63D) rarely develop clinically significant iron overload. Indeed, in compound heterozygotes, additional factors such as alcohol excess or the metabolic syndrome likely contribute to any hyperferritinaemia more than the molecular abnormality itself.

Diagnosis

If ferritin is raised (>300mcg/l in men & postmenopausal women, or >200mcg/l in premenopausal women) then transferrin saturations should be checked. Ferritin is an acute phase protein so can be raised with intercurrent illness.

If fasting transferrin saturation is >50% in men or postmenopausal women or >40% in premenopausal men then an HFE genotype should be requested.

Referral

If the HFE gene confirms C282Y homozygosity, they should be referred to a Haemochromatosis specialist. In C282Y homozygotes, with serum ferritin >1000, there is an increased risk of hepatic fibrosis and they should be referred to gastro/liver specialist to undertake fibrosis assessment.

However, there are many causes for an isolated raised serum ferritin. These include intercurrent illness, a wide range of inflammatory conditions, alcohol excess, metabolic syndrome and malignancy. Therefore a raised serum ferritin on its own is not diagnostic of genetic haemochromatosis.

Patients >18 years old with a first degree relative with genetic haemochromatosis should be screened for haemochromatosis with ferritin, transferrin saturations and HFE genotype.

References

Fitzsimmons et al. Diagnosis and therapy of genetic haemochromatosis (review and 2017 update). British Journal of Haematology, 2018, 181, 293–303
Cullis et al. Investigation and management of a raised serum ferritin. British Journal of Haematology, 2018, 181, 331–340

Caeruloplasmin

Caeruloplasmin is a copper binding protein. It is requested as part of a liver disease to screen for Wilson’s disease.

Levels can be reduced in:

Wilson’s disease
Severe liver disease of any aetiology
Malnutrition

Levels can be raised in:

Any form of infection or inflammation as it is an acute phase reactant
Pregnancy
Oestrogen therapy

Wilson’s disease is an autosomal recessive disorder. It is caused by various mutations in a gene (ATP7B) on chromosome 13. In Wilson’s disease there is a defect in hepatic copper metabolism which causes decreased hepatocellular excretion of copper into bile. This results in accumulation of copper within the liver which is toxic to hepatocytes. Copper is then released into the bloodstream and is deposited in the kidneys, brain and cornea.

Wilson’s disease usually present in childhood or early adulthood. Most patients present with acute or chronic liver disease, neurological or psychiatric symptoms.

Diagnostic features are:

Low caeruloplasmin
Low serum copper
Increased 24 hour urinary copper
Normal or low alkaline phosphatase
Haemolytic anaemia
Kayser-Fleischer rings
Raised hepatic dry weight copper content

Wilson’s disease can be very challenging to diagnose and patients with suspected Wilson’s disease should be discussed with and or referred to a hepatologist.

Alpha-1 antitrypsin

Alpha-1 antitrypsin is an enzyme inhibitor which is produced by hepatocytes and transported to the lungs. It protects the lungs against the proteases released by inflammatory cells, particularly neutrophils.

Alpha-1 antitrypsin deficiency is an inherited disorder which increases the risk of chronic obstructive pulmonary disorder (COPD) and chronic liver disease. It is characterised by low levels of alpha-1 antitrypsin. If low levels are detected then phenotyping studies should be done. There are a number of different phenotypes which are coded by the allele which has been inherited. The different phenotypes confer different risks of patients having lung or liver disease. Patients with liver disease are at risk of cirrhosis and hepatocellular carcinoma.

Patients with suspected or confirmed alpha-1 antitrypsin deficiency should be discussed and or referred to a hepatologist for assessment.

The contents of these pages were created with great care. For the accuracy, completeness and timeliness of content, we can not take any responsibility. As a service provider we are responsible according §7 1 TMG for own contents on these pages under the general laws. According to §8 to 10 TMG we are not obligated as a service provider to monitor transmitted or stored information, or to investigate circumstances that indicate illegal activity. Obligations to remove or block the use of information under the general laws remain unaffected. However, a relevant liability is only possible from the date of knowledge of a specific infringement. Upon notification of such violations, we will remove the content immediately.

Privacy Policy of Buku Haematology

This Application collects some Personal Data from its Users.

This document can be printed for reference by using the print command in the settings of any browser.

Owner and Data Controller

Buku Haematology - Newcastle - United Kingdom

Owner contact email: bukuhaem@gmail.com

Types of Data collected

Buku Haematology (The Owner) records no personally identifiable data. The following usage data are collected by default by the host of our App, AppYourself GmbH. This data is then managed as per their privacy policy below.

System Version
Smartphone model
Hardware ID (https://help.pushwoosh.com/hc/en-us/articles/360000365023-What-is-a-HWID-)
Opening of each module together with the time of the action
Date of register

Data will only be shared by AppYourself in accordance with their Privacy Policy.

Buku Haematology (owned by Buku Tech Ltd) retain none of this data. We can see our user traffic, country of access and modules accessed. Unique identifiers are generated for each user by the AppYourself system to show the number of times the App is accessed and which modules are viewed by individuals. No further information about the individual is given.

AppYourself privacy policy

We (Buku Haematology) have removed those elements that we have chosen not to include in the App (such as Facebook integration for example). Please contact privacy@appyourself.net if you have any questions about personal data storage.

Among the types of Personal Data that this Application collects, by itself or through third parties, there are: Cookies; Usage Data; various types of Data; unique device identifiers for advertising (Google Advertiser ID or IDFA, for example); Storage permission; geographic position.

Complete details on each type of Personal Data collected are provided in the dedicated sections of this privacy policy or by specific explanation texts displayed prior to the Data collection.

Personal Data may be freely provided by the User, or, in case of Usage Data, collected automatically when using this Application.

Unless specified otherwise, all Data requested by this Application is mandatory and failure to provide this Data may make it impossible for this Application to provide its services. In cases where this Application specifically states that some Data is not mandatory, Users are free not to communicate this Data without consequences to the availability or the functioning of the Service.

Any use of Cookies – or of other tracking tools – by this Application or by the owners of third-party services used by this Application serves the purpose of providing the Service required by the User, in addition to any other purposes described in the present document and in the Cookie Policy, if available.

Mode and place of processing the Data

Methods of processing

In some cases, the Data may be accessible to certain types of persons in charge, involved with the operation of this Application (administration, sales, marketing, legal, system administration) or external parties (such as third-party technical service providers, mail carriers, hosting providers, IT companies, communications agencies) appointed, if necessary, as Data Processors by the Owner. The updated list of these parties may be requested from the Owner at any time.

Legal basis of processing

The Owner may process Personal Data relating to Users if one of the following applies:

Users have given their consent for one or more specific purposes. Note: Under some legislations the Owner may be allowed to process Personal Data until the User objects to such processing (“opt-out”), without having to rely on consent or any other of the following legal bases. This, however, does not apply, whenever the processing of Personal Data is subject to European data protection law;
provision of Data is necessary for the performance of an agreement with the User and/or for any pre-contractual obligations thereof;
processing is necessary for compliance with a legal obligation to which the Owner is subject;
processing is related to a task that is carried out in the public interest or in the exercise of official authority vested in the Owner;
processing is necessary for the purposes of the legitimate interests pursued by the Owner or by a third party.

In any case, the Owner will gladly help to clarify the specific legal basis that applies to the processing, and in particular whether the provision of Personal Data is a statutory or contractual requirement, or a requirement necessary to enter into a contract.

Retention time

Personal Data shall be processed and stored for as long as required by the purpose they have been collected for.

The Owner records no personal data, and therefore usage data is the only data retained, and this is retained by AppYourself.

Once the retention period expires, Personal Data shall be deleted. Therefore, the right to access, the right to erasure, the right to rectification and the right to data portability cannot be enforced after expiration of the retention period.

The purposes of processing

The Data concerning the User is collected for the following purposes: Analytics, Hosting and backend infrastructure, Data transfer outside the EU, Device permissions for Personal Data access, Displaying content from external platforms, Infrastructure monitoring, Registration and authentication, and Location-based interactions.

For specific information about the Personal Data used for each purpose, the User may refer to the section “Detailed information on the processing of Personal Data”.

Detailed information on the processing of Personal Data

Key facts about data control by AppYourself;

The servers used by AppYourself are located in Europe (and thus protected by GDPR) and the US.
The data is hosted on AWS infrastructure, but AWS does not store any user-related data. User-related data is stored by AppYourself in Google Firebase. The storage is located in USA.
Although the Google Firebase server (based in the US) is not secured by GDPR they operate under the EU-US privacy shield. For more information about cloud-sided encryption see; https://firebase.google.com/support/privacy#data_encryption. Google Firebase is also compliant with ISO27001. For more information see; https://firebase.google.com/support/privacy#firebase_is_certified_under_major_privacy_and_security_standards
User data is stored for up to 90 days after App subscription is terminated. Furthermore, users have the right to delete their profile at any time. By doing so, their account is irretrievably deleted.
In case of a data breach by AppYourself, this can be reported via https://iapp.org/resources/article/how-to-notify-your-dpa-of-a-data-breach/

Personal Data is collected for the following purposes and using the following services:

Analytics

The services contained in this section enable the Owner to monitor and analyze web traffic and can be used to keep track of User behavior.

Google Analytics for Firebase (Google LLC)

Google Analytics for Firebase or Firebase Analytics is an analytics service provided by Google LLC.

In order to understand Google's use of Data, consult Google's partner policy.

Firebase Analytics may share Data with other tools provided by Firebase, such as Crash Reporting, Authentication, Remote Config or Notifications. The User may check this privacy policy to find a detailed explanation about the other tools used by the Owner.

This Application uses identifiers for mobile devices and technologies similar to cookies to run the Firebase Analytics service.

Users may opt-out of certain Firebase features through applicable device settings, such as the device advertising settings for mobile phones or by following the instructions in other Firebase related sections of this privacy policy, if available.

Personal Data processed: Cookies; unique device identifiers for advertising (Google Advertiser ID or IDFA, for example); Usage Data.

Place of processing: United States – Privacy Policy. Privacy Shield participant.

Data transfer outside the EU

Any data collected by AppYourself is transferred in keeping with these statements.

The Google Firebase services used to store and transfer data provide HTTPS encryption during information transit. Data encryption is also provided for cloud data storage. See https://firebase.google.com/support/privacy#data_encryption for more information.

Data transfer from the EU and/or Switzerland to the U.S based on Privacy Shield (this Application)

If this is the legal basis, the transfer of Personal Data from the EU or Switzerland to the US is carried out according to the EU - U.S. and Swiss - U.S. Privacy Shield.

In particular, Personal Data is transferred to services that self-certify under the Privacy Shield framework and therefore guarantee an adequate level of protection of such transferred Data. All services are listed within the relevant section of this document and those that adhere to Privacy Shield can be singled out by checking their privacy policy and possibly also by specifically checking for Privacy Shield adherence in the official Privacy Shield List. Privacy Shield also specifically guarantees rights to Users which can be found in its most current form on the website run by the US Department of Commerce.

Personal Data may be transferred from within the EU or Switzerland to the U.S. to services that are not, or not anymore, part of Privacy Shield, only based on other valid legal grounds. Users can ask the Owner to learn about such legal grounds.

Personal Data processed: various types of Data.

Data transfer to countries that guarantee European standards (this Application)

If this is the legal basis, the transfer of Personal Data from the EU to third countries is carried out according to an adequacy decision of the European Commission.

The European Commission adopts adequacy decisions for specific countries whenever it considers that country to possess and provide Personal Data protection standards comparable to those set forth by EU data protection legislation. Users can find an updated list of all adequacy decisions issued on the European Commission's website.

Personal Data processed: various types of Data.

Device permissions for Personal Data access

This Application requests certain permissions from Users that allow it to access the User's device Data as described below.

Device permissions for Personal Data access (this Application)

This Application requests certain permissions from Users that allow it to access the User's device Data as summarized here and described within this document.

Personal Data processed: Storage permission.

Hosting and backend infrastructure

This type of service has the purpose of hosting Data and files that enable this Application to run and be distributed as well as to provide a ready-made infrastructure to run specific features or parts of this Application. Some of these services work through geographically distributed servers, making it difficult to determine the actual location where the Personal Data are stored.

Firebase Cloud Functions (Google LLC)

Firebase Cloud Functions is a hosting and backend service provided by Google LLC.

Personal Data processed: Usage Data; various types of Data as specified in the privacy policy of the service.

Place of processing: United States – Privacy Policy. Privacy Shield participant.

Firebase Cloud Firestore (Google LLC)

Firebase Cloud Firestore is a hosting and backend service provided by Google LLC.

Personal Data processed: Usage Data; various types of Data as specified in the privacy policy of the service.

Place of processing: United States – Privacy Policy. Privacy Shield participant.

Firebase Realtime Database (Google LLC)

Firebase Realtime Database is a hosting and backend service provided by Google LLC.

Personal Data processed: Usage Data; various types of Data as specified in the privacy policy of the service.

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Firebase Cloud Storage (Google LLC)

Firebase Cloud Storage is a hosting service provided by Google LLC.

Personal Data processed: Usage Data; various types of Data as specified in the privacy policy of the service.

Place of processing: United States – Privacy Policy. Privacy Shield participant.

Interoute (Interoute Communications Limited.)

Interoute is a hosting service provided by Interoute Communications Limited.

Personal Data processed: various types of Data as specified in the privacy policy of the service.

Place of processing: United Kingdom – Privacy Policy.

Infrastructure monitoring

This type of service allows this Application to monitor the use and behavior of its components so its performance, operation, maintenance and troubleshooting can be improved.

Which Personal Data are processed depends on the characteristics and mode of implementation of these services, whose function is to filter the activities of this Application.

Sentry (Functional Software, Inc. )

Sentry is a monitoring service provided by Functional Software, Inc. .

Personal Data processed: various types of Data as specified in the privacy policy of the service.

Place of processing: United States – Privacy Policy.

Managing contacts and sending messages

This type of service makes it possible to manage a database of email contacts, phone contacts or any other contact information to communicate with the User.

These services may also collect data concerning the date and time when the message was viewed by the User, as well as when the User interacted with it, such as by clicking on links included in the message.

Firebase Cloud Messaging (Google Inc.)

Firebase Cloud Messaging is a message sending service provided by Google, Inc. Firebase Cloud Messaging allows the Owner to send messages and notifications to Users across platforms such as Android, iOS, and the web. Messages can be sent to single devices, groups of devices, or specific topics or User segments.

Personal Data processed: various types of Data as specified in the privacy policy of the service.

Place of processing: United States – Privacy Policy. Privacy Shield participant.

Further information about Personal Data

Push notifications

This Application may send push notifications to the User.

Unique device identification

This Application may track Users by storing a unique identifier of their device, for analytics purposes or for storing Users' preferences.

The rights of Users

Users may exercise certain rights regarding their Data processed by AppYourself.

In particular, Users have the right to do the following:

Withdraw their consent at any time. Users have the right to withdraw consent where they have previously given their consent to the processing of their Personal Data.
Object to processing of their Data. Users have the right to object to the processing of their Data if the processing is carried out on a legal basis other than consent. Further details are provided in the dedicated section below.
Access their Data. Users have the right to learn if Data is being processed by the Owner, obtain disclosure regarding certain aspects of the processing and obtain a copy of the Data undergoing processing.
Verify and seek rectification. Users have the right to verify the accuracy of their Data and ask for it to be updated or corrected.
Restrict the processing of their Data. Users have the right, under certain circumstances, to restrict the processing of their Data. In this case, the Owner will not process their Data for any purpose other than storing it.
Have their Personal Data deleted or otherwise removed. Users have the right, under certain circumstances, to obtain the erasure of their Data from the Owner.
Receive their Data and have it transferred to another controller. Users have the right to receive their Data in a structured, commonly used and machine readable format and, if technically feasible, to have it transmitted to another controller without any hindrance. This provision is applicable provided that the Data is processed by automated means and that the processing is based on the User's consent, on a contract which the User is part of or on pre-contractual obligations thereof.
Lodge a complaint. Users have the right to bring a claim before their competent data protection authority.

Cookie Policy

This Application uses Cookies and other Identifiers. To learn more, the User may consult the Cookie Policy.

Additional information about Data collection and processing

Legal action

The User's Personal Data may be used for legal purposes by the Owner in Court or in the stages leading to possible legal action arising from improper use of this Application or the related Services.

The User declares to be aware that the Owner may be required to reveal personal data upon request of public authorities.

Additional information about User's Personal Data

In addition to the information contained in this privacy policy, this Application may provide the User with additional and contextual information concerning particular Services or the collection and processing of Personal Data upon request.

System logs and maintenance

For operation and maintenance purposes, this Application and any third-party services may collect files that record interaction with this Application (System logs) use other Personal Data (such as the IP Address) for this purpose.

Information not contained in this policy

More details concerning the collection or processing of Personal Data may be requested from the Owner at any time. Please see the contact information at the beginning of this document.

How “Do Not Track” requests are handled

This Application does not support “Do Not Track” requests.

To determine whether any of the third-party services it uses honor the “Do Not Track” requests, please read their privacy policies.

Changes to this privacy policy

The Owner reserves the right to make changes to this privacy policy at any time by notifying its Users on this page and possibly within this Application and/or - as far as technically and legally feasible - sending a notice to Users via any contact information available to the Owner. It is strongly recommended to check this page often, referring to the date of the last modification listed at the bottom.

Should the changes affect processing activities performed on the basis of the User’s consent, the Owner shall collect new consent from the User, where required.

Definitions and legal references

Personal Data (or Data)

Any information that directly, indirectly, or in connection with other information — including a personal identification number — allows for the identification or identifiability of a natural person.

Usage Data

Information collected automatically through this Application (or third-party services employed in this Application), which can include: the IP addresses or domain names of the computers utilized by the Users who use this Application, the URI addresses (Uniform Resource Identifier), the time of the request, the method utilized to submit the request to the server, the size of the file received in response, the numerical code indicating the status of the server's answer (successful outcome, error, etc.), the country of origin, the features of the browser and the operating system utilized by the User, the various time details per visit (e.g., the time spent on each page within the Application) and the details about the path followed within the Application with special reference to the sequence of pages visited, and other parameters about the device operating system and/or the User's IT environment.

User

The individual using this Application who, unless otherwise specified, coincides with the Data Subject.

Data Subject

The natural person to whom the Personal Data refers.

Data Processor (or Data Supervisor)

The natural or legal person, public authority, agency or other body which processes Personal Data on behalf of the Controller, as described in this privacy policy.

Data Controller (or Owner)

The natural or legal person, public authority, agency or other body which, alone or jointly with others, determines the purposes and means of the processing of Personal Data, including the security measures concerning the operation and use of this Application. The Data Controller, unless otherwise specified, is the Owner of this Application.

This Application

The means by which the Personal Data of the User is collected and processed.

Service

The service provided by this Application as described in the relative terms (if available) and on this site/application.

European Union (or EU)

Unless otherwise specified, all references made within this document to the European Union include all current member states to the European Union and the European Economic Area.

Cookies

Small sets of data stored in the User's device.

Legal information

This privacy statement has been prepared based on provisions of multiple legislations, including Art. 13/14 of Regulation (EU) 2016/679 (General Data Protection Regulation).

This privacy policy relates solely to this Application, if not stated otherwise within this document.

Latest update: May 17, 2018

Cookie Policy of Buku Haematology

Cookies and other Identifiers consist of portions of code placed on the User’s device that assist the Owner in providing the Service according to the purposes described.

Some of the purposes for which Identifiers are used may also require the User's consent. Whenever consent is given, it can be freely withdrawn at any time following the instructions provided in this document.

Activities strictly necessary for the operation of this Application and delivery of the Service

This Application uses Cookies or other Identifiers to carry out activities that are strictly necessary for the operation or delivery of the Service and, therefore, do not require Users to consent. Users can disable such Identifiers by modifying their browser or device settings as described in more detail within this document, but this may affect core operational functions or result in the unavailability of the Service.

Other activities

Experience enhancement

This Application uses Cookies or other Identifiers to provide a personalized user experience by improving the quality of preference management options, and by enabling interaction with external networks and platforms.

Measurement

This Application uses Cookies or other Identifiers to measure traffic and analyze User behavior with the goal of improving the Service.

Analytics

The services contained in this section enable the Owner to monitor and analyze web traffic and can be used to keep track of User behavior.

Google Analytics for Firebase (Google LLC)

Google Analytics for Firebase or Firebase Analytics is an analytics service provided by Google LLC.

In order to understand Google's use of Data, consult Google's partner policy.

This Application uses identifiers for mobile devices and technologies similar to cookies to run the Firebase Analytics service.

Personal Data processed: Cookies, unique device identifiers for advertising (Google Advertiser ID or IDFA, for example) and Usage Data.

Place of processing: United States – Privacy Policy. Privacy Shield participant.

How to provide or withdraw consent

Users can provide or withdraw consent to the use of Cookies and other Identifiers by setting their preferences within the cookie notice or by updating such preferences via the relevant consent-preferences widget accordingly, if available.

Additionally, Users can manage preferences regarding Identifiers directly from within their own device settings and prevent – for example – the storing of third-party Identifiers. It is also possible, via relevant browser or device features, to delete previously stored Identifiers, including those used to remember the User’s initial consent. Users can, for example, find information about how to manage Identifiers in the most commonly used browsers at the following addresses: Google Chrome, Mozilla Firefox, Apple Safari and Microsoft Internet Explorer.

With regard to any Identifiers stored by third parties, Users can manage their preferences and withdraw their consent by clicking the related opt-out link (where provided), by using the means indicated in the third party's privacy policy, or by contacting the third party.

Notwithstanding the above, Users are hereby informed that they may follow the instructions provided by YourOnlineChoices (EU), the Network Advertising Initiative (US) and the Digital Advertising Alliance (US), DAAC (Canada), DDAI (Japan) or other similar services. Such initiatives allow Users to select their tracking preferences for most of the advertising tools. The Owner thus recommends that Users make use of these resources in addition to the information provided in this document.

Owner and Data Controller

Buku Haematology - Newcastle - United Kingdom

Owner contact email: bukuhaem@gmail.com

Since the storing of third-party Cookies and other Identifiers through the services used within this Application cannot be technically controlled by the Owner, any specific references to Identifiers stored by third parties are to be considered indicative. In order to obtain complete information, the User is kindly requested to consult the privacy policies of the respective third-party services listed in this document.

Given the objective complexity surrounding technologies related to Cookies and other Identifiers, Users are encouraged to contact the Owner should they wish to receive any further information on the use of such Identifiers by this Application.

Definitions and legal references

Personal Data (or Data)

Usage Data

User

The individual using this Application who, unless otherwise specified, coincides with the Data Subject.

Data Subject

The natural person to whom the Personal Data refers.

Data Processor (or Data Supervisor)

The natural or legal person, public authority, agency or other body which processes Personal Data on behalf of the Controller, as described in this privacy policy.

Data Controller (or Owner)

This Application

The means by which the Personal Data of the User is collected and processed.

Service

The service provided by this Application as described in the relative terms (if available) and on this site/application.

European Union (or EU)

Unless otherwise specified, all references made within this document to the European Union include all current member states to the European Union and the European Economic Area.

Cookie

Cookies are Identifiers consisting of small sets of data stored in the User's browser.

Identifier

Any technology - including Cookies - that allows for the storing of information, or the accessing of already-stored information, on the User’s device.

Legal information

This privacy statement has been prepared based on provisions of multiple legislations, including Art. 13/14 of Regulation (EU) 2016/679 (General Data Protection Regulation).

This privacy policy relates solely to this Application, if not stated otherwise within this document.

Buku Medicine

Introduction

Hepatitis B

Hepatitis C

Liver autoantibodies

Ferritin

Caeruloplasmin

Alpha-1 antitrypsin