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You, Your Liver and Alpha-1

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You, Your Liver and Alpha-1 You, Your Liver and Alpha-1 Skinny Little Reference Guide™ THE LIVER IN ALPHA-1 ANTITRYPSIN DEFICIENCY Alpha-1 Antitrypsin Deficiency, or Alpha-1, is a genetic condition that can cause disease of the lungs, liver, skin, and blood vessels. Although the first descriptions of Alpha-1 pointed to its role in the promotion of lung disease in adults, in fact, Alpha-1 is primarily a condition caused by problems in the liver. Liver disease in Alpha-1 can occur in newborns, children, and adults. This guide is intended to be used by the parent of a child with Apha-1, or an individual who has Alpha-1, and by their healthcare providers. It is always important to confirm the diagnosis of Alpha-1 if this has not been done. The diagnosis of Alpha-1 rests on identifying the presence of abnormal AAT protein (usually the Z protein) in a sample of the patient’s blood (phenotype or “PI-type” testing). Diagnosis can also be made by looking for abnormalities in the AAT gene, again by testing a sample of blood. Usually these tests are accompanied by a measurement of AAT level in the blood. INTRODUCTION TO ALPHA-1 LIVER DISEASE Normally, the alpha-1 antitrypsin protein or AAT is made in large quantities within the liver and then released into the blood. However, individuals who carry two abnormal genes for Alpha-1 (usually two “Z” genes, with the “M” gene considered normal) produce an abnormal AAT protein which is unable to be released from the liver cells. Therefore, the AAT accumulates within the liver, resulting in a deficiency, or low levels, of AAT in the blood. While the lung damage in Alpha 1 appears to be directly related to the low blood level of AAT, the liver is thought to be damaged by the unusual internal buildup of the abnormal Z protein. Additional information about Alpha-1 is available in AlphaNet's Big Fat Reference Guide to Alpha-1 (the BFRG), which is available on the AlphaNet website (www.alphanet.org). 1 Copyright© AlphaNet, Inc. 2009 Since most of the research into Alpha-1 liver disease has been performed on the duct, to mix with food and to assist in fat digestion and removal of nutrients Z protein, we will use Z as the basis for this guide. There are many other types present within certain fats. The bile is then removed from the intestine, of AAT gene variants that can cause Alpha-1 and some may have slightly transferred to the blood stream for transport back to the liver, and then different mechanisms. recycled by liver cells to be used again. A portion of bile remains within the intestinal contents and this is what gives stool its characteristic brown color. KEY LEARNING: While the lung damage in Alpha 1 appears to be The liver has its very own unique blood supply called the “portal directly related to the low blood level of AAT, the liver is thought circulation.” The portal circulation carries blood from the intestines and to be damaged by the unusual internal buildup of the abnormal stomach to the liver and spleen. The portal circulation becomes more AAT protein. important later, when we discuss liver diseases. In order to begin to understand the liver disease associated with Alpha-1 EXCRETORY FUNCTION. The liver participates in waste removal from the it is useful to review the basic functions of the liver under normal conditions body in several ways. First, toxins ingested with food are cleared by the liver and to discuss the medical techniques used to assess liver health. as the blood from the intestines passes through. Some of those wastes are then processed within liver cells into substances useful to the body and some wastes are inactivated within liver cells, transferred into the bile, drained into the FUNCTIONS OF THE NORMAL LIVER intestine and then eliminated in the stool. Some wastes from other parts of the body are transferred to the liver by the blood stream for processing and/or removal via the bile and stool. The functions of the liver remain pretty much the same throughout someone’s A similar mechanism is used by the body to clear certain drugs and life, from birth through old age, although a newborn’s liver may require time medications from the circulation. These medications are broken down and to fully mature. inactivated in the liver, then sent out of the body in the bile or urine. SYNTHETIC FUNCTION. The liver manufactures a large number of proteins and other substances crucial to the normal function of many parts VISITS WITH YOUR HEALTHCARE PROVIDER of the body. Many components of the liquid, non-cellular portion of the blood are made in the liver. Some of these substances are critical to normal blood You may seek medical attention because you’re just not feeling well or because clotting, important in allowing normal distribution of salts, fluid and nutrients you’ve noticed a change in your usual health or are experiencing a particular to the body via the blood stream, and vital to supplying energy to the body problem or symptom and are especially concerned because you have Alpha-1. during exercise and fasting. You may seek medical attention because you have Alpha-1 and are expecting a child. It is natural to wonder what the risks are of that child being born with IT’S A FACT: The liver is the body’s filter and distribution Alpha-1 and whether liver disease might occur during their childhood. center. Part of its function removes waste while it also generates life-sustaining proteins and substances to keep the body CROSS-REFERENCE: Alpha-1 genetic considerations are working smoothly. discussed in the Big Fat Reference Guide to Alpha-1 available at www.AlphaNet.org. DIGESTIVE FUNCTION. All of the blood leaving the intestines passes through the liver so that nutrients from food can be properly processed, stored, Whatever the reason for seeking medical care, the initial visit with your or distributed to other parts of the body. The liver also produces a substance healthcare provider will involve a thorough medical history and physical called bile. As bile is produced by liver cells it is stored in the gallbladder until examination as well as a variety of medical assessments in order to determine a meal is eaten. Then the bile drains into the intestine, via a tube called the bile if there is a problem and what to do about it. 2 3 GENERAL LIVER HEALTH ASSESSMENT Physicians will want to know about any occurrence of unusual bleeding. Bleeding problems may be related to poor vitamin K absorption or poor liver Physicians use many features of the patient’s history and physical examination, synthetic function. Similarly, the doctor will want to know about any unusual combined with other tests to form an overall opinion about whether the liver sleepiness or change in mental alertness because these can also be related to an is functioning properly. otherwise silent deterioration of the liver. MEDICAL HISTORY. First, the doctor may explore the patient’s health history for any features that could point to previous, unrecognized liver problems. This IT’S A FACT: The liver and nutrition are intimately linked. might include reviewing any history of jaundice (yellow skin and eyes) either as an infant, child, or adult, as well as any history of previous surgery, gallstones, kidney stones, serious injuries, hospitalizations, blood transfusions, or other Analysis of a number of health factors may figure into a doctor’s significant health events. The doctor will often review similar information about assessment of the contribution of the liver to a patient’s nutritional status. the patient’s close family members. Doctors will also commonly review risk Simple measures like height, weight, calculation of percent body fat, factors and known exposures to certain infections that can involve the liver. calculation of lean body mass (amount of non-fat body tissue) or a similar These may include hepatitis A, B, or C, tuberculosis, HIV, and/or sexually assessment called body mass index (BMI) are often very useful, especially transmitted diseases. Other risk factors include cancer and immune diseases. A in growing children. complete list of medications, herbs, and dietary supplements the patient has used Evaluation of the speed and quality of wound healing, the quality of a as well as alcohol and drug use and toxic exposures at work is usually obtained. patient’s skin and hair, and measurement of various blood protein levels also All of these can have a significant influence on liver health and should be can be informative regarding a person’s nutritional status and the possible thoroughly discussed with the doctor. The questions may be different for contribution of liver disease. adults and children with Alpha-1. Any history of potential liver problems will include questions about Individuals may be asked about specific symptoms which, if present, might alcohol consumption. While excessive use of alcoholic beverages are the be suspicious for liver problems but might not by themselves be conclusive. leading cause of liver problems in the world, sometimes even casual For example: consumption of alcohol can increase the risk of liver injury in those with • Diarrhea can have many causes, but is often reported in both adults other risk factors, including Alpha-1. and children with abnormalities of bile flow and inadequate fat digestion. • Itching is a common complaint of patients with significant liver disease. PHYSICAL EXAMINATION. When a physician proceeds to the physical This itching is caused by buildup within the skin of waste products that examination, he or she will pay special attention to body features that may are not being adequately removed from the blood by the liver.
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