DOCSLIB.ORG

042700 Evaluation of Abnormal Liver-Enzyme Results

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
042700 Evaluation of Abnormal Liver-Enzyme Results The New England Journal of Medicine Primary Care recommend adjusting aminotransferase values for sex and body-mass index,2 but these adjustments are rare- ly made. Aspartate aminotransferase is found, in de- creasing order of concentration, in the liver, cardiac EVALUATION OF ABNORMAL muscle, skeletal muscle, kidneys, brain, pancreas, lungs, LIVER-ENZYME RESULTS IN leukocytes, and erythrocytes. The highest level of ASYMPTOMATIC PATIENTS alanine aminotransferase is in the liver, and levels of this enzyme are accordingly more specific indicators of liver injury. Both enzymes are released into the DANIEL S. PRATT, M.D., AND MARSHALL M. KAPLAN, M.D. blood in increasing amounts when the liver cell mem- brane is damaged. Necrosis of liver cells is not re- quired for the release of the aminotransferases. In OW that routine laboratory testing is auto- fact, there is poor correlation between the degree of mated and is frequently part of an annual liver-cell damage and the level of the aminotransfer- checkup, physicians are often faced with the ases.1 If the aminotransferase levels are normal on re- N testing, no further evaluation is necessary. If the results problem of a patient with one abnormal result on measurement of serum aminotransferases or alkaline of repeated tests remain abnormal, further evaluation phosphatase but no symptoms. Many batteries of is indicated. screening tests now include measurement of serum The first step in the evaluation is to obtain a com- alanine aminotransferase, aspartate aminotransferase, plete history in an effort to identify the most com- alkaline phosphatase, and g-glutamyltransferase. Al- mon causes of elevated aminotransferase levels: alco- though these enzymes are present in tissues through- hol-related liver injury, chronic hepatitis B and C, out the body, they are most often elevated in pa- autoimmune hepatitis, hepatic steatosis (fatty infiltra- tients with liver disease and may reflect liver injury. tion of the liver), nonalcoholic steatohepatitis, hemo- The first step in the evaluation of a patient with chromatosis, Wilson’s disease, alpha1-antitrypsin de- elevated liver-enzyme levels but no symptoms is to ficiency, and a recently recognized cause, celiac sprue repeat the test to confirm the result. If the result is (Table 1). Table 2 lists the blood tests that can be still abnormal, the physician should evaluate the de- used to identify many of these disorders. It is more gree of the elevation. A minor elevation (less than efficient to order all the blood tests in the first group twice the normal value) may be of no clinical impor- initially, unless the history strongly suggests a defi- tance if the disorders listed in Table 1 have been nite diagnosis, such as alcohol abuse. The cause of ruled out and, in fact, may not even be abnormal. the aminotransferase elevation can usually be identi- The normal range for any laboratory test is the mean fied on assessment of the pattern of the results of liv- value in a group of healthy persons ±2 SD. Thus, er-enzyme tests and additional testing. 5 percent of the results obtained from these normal The cause of an elevated alanine aminotransferase persons fall outside the defined normal range, 2.5 level varies greatly depending on the population stud- percent of which may be above the upper limit of ied. Among 19,877 Air Force trainees who volun- normal. There are also circumstances in which ele- teered to donate blood, 99 (0.5 percent) had elevat- vations in liver-enzyme levels are physiologic; for ex- ed alanine aminotransferase levels.3 A cause for the ample, alkaline phosphatase levels are increased in elevation was found in only 12: 4 had hepatitis B, healthy women during the third trimester of preg- 4 had hepatitis C, 2 had autoimmune hepatitis, 1 had nancy. The evaluation of the patient with an isolated cholelithiasis, and 1 had acute appendicitis. In a group elevation of an aminotransferase differs from that for of 100 consecutive blood donors with elevated ala- a patient with an isolated elevation of alkaline phos- nine aminotransferase levels, 48 percent had changes phatase or g-glutamyltransferase. related to alcohol use, 22 percent had fatty liver, 17 percent had hepatitis C, 4 percent had another iden- AMINOTRANSFERASE LEVELS tified problem, and in the remaining 9 percent, no Aminotransferase levels are sensitive indicators of specific diagnosis was made.4 In another study of liver-cell injury and are helpful in recognizing hepa- 149 asymptomatic patients with elevated alanine ami- tocellular diseases such as hepatitis.1 Both aminotrans- notransferase levels who underwent liver biopsy, 56 ferases are normally present in serum at low levels, usu- percent had fatty liver, 20 percent had non-A, non- ally less than 30 to 40 U per liter. The normal range B hepatitis, 11 percent had changes related to alco- varies widely among laboratories. Some researchers hol use, 3 percent had hepatitis B, 8 percent had other causes, and in 2 percent, no cause was identi- fied.5 A recent study assessed 1124 consecutive pa- tients who were referred for chronic elevations in ami- From New England Medical Center, Box 217, 750 Washington St., Bos- 6 ton, MA 02111, where reprint requests should be addressed to Dr. Pratt. notransferase levels. Eighty-one of these patients had ©2000, Massachusetts Medical Society. no definable cause of the elevation and underwent a 1266 · April 27, 2000 Downloaded from www.nejm.org at COLUMBIA UNIV HEALTH SCIENCES LIB on August 3, 2009 . Copyright © 2000 Massachusetts Medical Society. All rights reserved. PRIMARY CARE CAUSES OF ELEVATED TABLE 1. CAUSES OF CHRONICALLY ELEVATED AMINOTRANSFERASE LEVELS AMINOTRANSFERASE LEVELS. Alcohol Abuse Hepatic causes The diagnosis of alcohol abuse can be difficult be- Alcohol abuse Medication cause many patients conceal information about their Chronic hepatitis B and C alcohol use. The diagnosis is supported by the find- Steatosis and nonalcoholic steatohepatitis Autoimmune hepatitis ing of a ratio of aspartate aminotransferase to alanine Hemochromatosis aminotransferase of at least 2:1. In a study of hun- Wilson’s disease (in patients «40 years old) dreds of patients who had histologically confirmed Alpha -antitrypsin deficiency 1 liver disorders, more than 90 percent of the patients Nonhepatic causes who had an aspartate aminotransferase:alanine ami- Celiac sprue Inherited disorders of muscle metabolism notransferase ratio of at least 2:1 had alcoholic liver Acquired muscle diseases disease.7 The percentage increased to more than 96 Strenuous exercise percent when the ratio was greater than 3:1. The in- creased ratio reflects primarily the low serum activity of alanine aminotransferase in patients with alcohol- ic liver disease. This decrease is due to an alcohol- related deficiency of pyridoxal 5-phosphate.8 Measurement of g-glutamyltransferase may also be helpful in diagnosing alcohol abuse. A g-glutamyl- TABLE 2. LABORATORY TESTS THAT MAY IDENTIFY THE CAUSE OF ELEVATED AMINOTRANSFERASE LEVELS IN A PATIENT transferase level that is twice the normal level in pa- WITH NO SYMPTOMS. tients with an aspartate aminotransferase:alanine ami- notransferase ratio of at least 2:1 strongly suggests the diagnosis of alcohol abuse. However, the lack of TEST DIAGNOSIS specificity of the g-glutamyltransferase level precludes Initial tests its use as a single test to diagnose alcohol abuse. Test for hepatitis C antibody in Presence of hepatitis C antibody indi- The degree of elevation of aminotransferase levels serum cates chronic hepatitis C Test for hepatitis B surface anti- Presence of hepatitis B surface antigen may also be helpful in identifying alcohol abuse. It gen, surface antibody, and and core antibody indicates chronic is rare for the aspartate aminotransferase level to be core antibody in serum hepatitis B Measurement of serum iron and Iron overload suggests hemochroma- more than eight times the normal value in patients total iron-binding capacity tosis with alcohol abuse, and it is even less common for Measurement of serum cerulo- Decreased ceruloplasmin levels suggest the alanine aminotransferase level to be more than plasmin Wilson’s disease (if patient is «40 7 years old) five times the normal value in such patients. In fact, Serum protein electrophoresis Increase in polyclonal immunoglobu- the alanine aminotransferase level may be normal, even lins suggests autoimmune hepatitis in patients with severe alcoholic liver disease. Serum protein electrophoresis Marked decrease in a-globulin bands suggests alpha1-antitrypsin deficiency Medication Additional tests* Reverse-transcriptase polymer- Presence of viral RNA indicates chronic A careful history-taking and meticulous review of ase chain reaction for hepati- hepatitis C laboratory data are critical for identifying a medica- tis C virus RNA Alpha1-antitrypsin phenotyping Presence of the ZZ phenotype indicates tion as the cause of elevated aminotransferase levels. alpha1-antitrypsin deficiency A drug effect is a possibility if the increase in liver- Tests for antiendomysial and an- Presence of antibodies indicates celiac tigliadin antibodies in serum sprue enzyme levels was associated with the initiation of a Measurement of creatine kinase Elevated enzyme levels indicate dis- medication. Almost any medication can cause an el- and aldolase orders of striated muscle evation in liver-enzyme levels. Common ones include *If the results of the initial set of tests are normal, these additional tests nonsteroidal antiinflammatory drugs, antibiotics, an- may pinpoint the cause. tiepileptic drugs, inhibitors of hydroxymethylglutar- yl–coenzyme A reductase, and antituberculosis drugs (Table 3). In addition to medications, herbal prepa- rations and illicit drugs or substances may cause el- evations in liver-enzyme levels (Table 3). liver biopsy. Of these 81 patients, 41 had steatosis, The easiest way to determine whether a medica- 26 had steatohepatitis, 4 had fibrosis, 2 had cirrho- tion is responsible for the elevation is to stop treat- sis, and 8 had normal histologic findings. The pa- ment and see whether the test results return to nor- tients with histologic evidence of fibrosis and cirrho- mal.
Load more

Recommended publications
  • Maximizing Diagnostic Value & Efficiency for Abnormal Lfts in The
    Maximizing Diagnostic Value & Efficiency for Abnormal LFTs in the Primary Care Setting Michael Kriss, MD Assistant Professor Associate Program Director, Transplant Hepatology Fellowship Division of Gastroenterology & Hepatology Section of Liver Disease & Transplantation University of Colorado School of Medicine Disclosures No conflicts of interest to disclose Learning Objectives At the completion of today’s talk, physicians will: 1. Recognize high value practices in evaluating and referring patients with abnormal liver enzymes 2. Identify essential components of the diagnostic evaluation of abnormal liver enzymes 3. Apply high value principles to complex patients requiring co-management by liver specialists https://www.ncbi.nlm.nih.gov/pubmed/27995906 https://www.ncbi.nlm.nih.gov/pubmed/27995906 Alcoholic liver disease Hepatitis B virus Primary biliary cholangitis NAFLD/NASH Hepatitis C virus Primary sclerosing cholangitis Autoimmune hepatitis Hemochromatosis Wilson’s disease https://www.aasld.org/publications/practice-guidelines What is normal…? ACG 2016 Guidelines “A true healthy normal ALT level in prospectively studied populations without identifiable risk factors for liver disease ranges from 29 to 33 IU/l for males and 19 to 25 IU/l for females, and levels above this should be assessed by physicians” “Clinicians may rely on local lab ULN ranges for alkaline phosphatase and bilirubin” Kwo PY et al. ACG Practice Guideline: Evaluation of Abnormal Liver Chemistries. AJG 2017 Critical to characterize pattern… Abnormal LFT 101 Hepatocellular Mixed Cholestatic AST/ALT Alk Phos Hyperbilirubinemia Bilirubin Kwo PY et al. ACG Practice Guideline: Evaluation of Abnormal Liver Chemistries. AJG 2017 Critical to characterize pattern… Abnormal LFT 101 ALT AP R = ALT ULN / AP ULN Hepatocellular Mixed Cholestatic AST/ALT R=2-5 Alk Phos R>5 R<2 Hyperbilirubinemia Bilirubin Kwo PY et al.
    [Show full text]
  • A New Tool for the Diagnosis of Choledocholithiasis. a Case Control Study
    DOI: https://doi.org/10.22516/25007440.446 Original article Elevated transaminases: a new tool for the diagnosis of choledocholithiasis. A case control study James Yurgaky-Sarmiento, MD,1 William Otero-Regino, MD,2* Martín Gómez-Zuleta, MD.3 Abstract OPEN ACCESS Introduction: Choledocolithiasis (CLD) affects 10% of patients with gallstones. Citation: Bile duct obstruction is associated with pancreatitis, cholangitis, and rupture of Yurgaky-Sarmiento J, Otero-Regino W, Gómez-Zuleta M. Elevated transaminases: a new tool the common bile duct. This condition usually presents with increased alkaline for the diagnosis of choledocholithiasis. A case control study. Un estudio de casos y controles. Rev Colomb Gastroenterol. 2020;35(3):319-328. https://doi.org/10.22516/25007440.446 phosphatase, GGTP and bilirubin levels. In the last decade, it has been found that up to 10% of patients with CLD have elevated aminotransferases levels. ............................................................................ In Latin America, this alteration has not been studied. The aim of the present 1 Internist, endocrinologist, gastroenterologist, Universidad Nacional de Colombia; Bogotá, work was to determine the prevalence of transaminase elevation and its evo- Colombia. lution. Methodology: Case-control study. ALT was measured on admission, 2 Professor of Medicine, Gastroenterology Coordinator, Universidad Nacional de Colombia, at 48 h and at 72 h. If ultrasound was normal, MRCP and/or echo-endoscopy Hospital Universitario Nacional de Colombia. Gastroenterologist, Clínica Fundadores; Bogotá, and ERCP were performed, as appropriate. Results: A total of 72 patients with Colombia. 3 Associate Professor of Medicine, Gastroenterology Unit, Universidad Nacional de Colombia, choledocholithiasis (CLD) (cases) and 128 with cholecystitis without choledo- Hospital Universitario Nacional de Colombia.
    [Show full text]
  • Elevated Transaminases During Medical Treatment of Acromegaly: A
    European Journal of Endocrinology (2006) 154 213–220 ISSN 0804-4643 CASE REPORT Elevated transaminases during medical treatment of acromegaly: a review of the German pegvisomant surveillance experience and a report of a patient with histologically proven chronic mild active hepatitis H Biering1, B Saller4,*, J Bauditz1, M Pirlich1, B Rudolph2, A Johne3, M Buchfelder5,*, K Mann6,*, M Droste7,*, I Schreiber4, H Lochs1 and C J Strasburger1,* 1Department of Gastroenterology, Hepatology and Endocrinology, 2Institute of Pathology and 3Institute for Clinical Pharmacology, Charite´-Universita¨tsmedizin Berlin, 10117 Berlin, Germany, 4Pfizer Pharma GmbH, Karlsruhe, Germany, 5Department of Neurosurgery, University Hosiptal, Erlangen, Germany, 6Division of Endocrinology, Department of Medicine, University of Duisberg-Essen, Germany and 7Oldenburg, Germany (Correspondence should be addressed to C J Strasburger, Division of Clinical Endocrinology, Department of Medicine, Charite´-Universita¨tsmedizin Berlin, Schumannstr. 20/21, 10117 Berlin, Germany; Email: [email protected]) *On behalf of the German pegvisomant investigators Abstract Objective: The new GH receptor antagonist pegvisomant is the most effective medical therapy to nor- malize IGF-I levels in patients with acromegaly. Based on currently available data pegvisomant is well tolerated; however, treatment-induced elevation of transaminases has been reported and led to the necessity for drug discontinuation in some patients in the pivotal studies. The aim of this study was to evaluate and characterize the prevalence of elevated transaminases and to describe in detail the findings in a single case who required drug discontinuation because of elevation of transaminases which emerged during treatment and who underwent liver biopsy. Design and methods: Retrospective safety analyses were carried out on 142 patients with acromegaly receiving pegvisomant treatment in Germany between March 2003 and the end of 2004.
    [Show full text]
  • Elevated Transaminases and Hypoalbuminemia in Covid-19 Are Prognostic Factors for Disease Severity
    www.nature.com/scientificreports OPEN Elevated transaminases and hypoalbuminemia in Covid‑19 are prognostic factors for disease severity Jason Wagner1, Victor Garcia‑Rodriguez1, Abraham Yu1, Barbara Dutra1, Scott Larson1, Brooks Cash1, Andrew DuPont1 & Ahmad Farooq2,3* Prognostic markers are needed to understand the disease course and severity in patients with Covid‑ 19. There is evidence that Covid‑19 causes gastrointestinal symptoms and abnormalities in liver enzymes. We aimed to determine if hepatobiliary laboratory data could predict disease severity in patients with Covid‑19. In this retrospective, single institution, cohort study that analyzed patients admitted to a community academic hospital with the diagnosis of Covid‑19, we found that elevations of Aspartate Aminotransferase (AST), Alanine Aminotransferase (ALT) and Alkaline Phosphatase (AP) at any time during hospital admission increased the odds of ICU admission by 5.12 (95% CI: 1.55–16.89; p = 0.007), 4.71 (95% CI: 1.51–14.69; p = 0.01) and 4.12 (95% CI: 1.21–14.06, p = 0.02), respectively. Hypoalbuminemia found at the time of admission to the hospital was associated with increased mortality (p = 0.02), hypotension (p = 0.03), and need for vasopressors (p = 0.02), intubation (p = 0.01) and hemodialysis (p = 0.002). Additionally, there was evidence of liver injury: AST was signifcantly elevated above baseline in patients admitted to the ICU (54.2 ± 15.70 U/L) relative to those who were not (9.2 ± 4.89 U/L; p = 0.01). Taken together, this study found that hypoalbuminemia and abnormalities in hepatobiliary laboratory data may be prognostic factors for disease severity in patients admitted to the hospital with Covid‑19.
    [Show full text]
  • Study of Serum Adenosine Deaminase and Transaminases in Type 2 Diabetes Mellitus
    IOSR Journal of Dental and Medical Sciences (IOSR-JDMS) e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 17, Issue 10 Ver. 4 (October. 2018), PP 12-16 www.iosrjournals.org Study of Serum Adenosine Deaminase and Transaminases in type 2 Diabetes Mellitus Sujeeta Oinam1, R.K. Vidyabati Devi2*, Th. Bhimo Singh3, WaikhomGyaneshwar Singh4 1Junior resident, Department of Biochemistry, Jawaharlal Nehru Institute of Medical Sciences, Porompat, Imphal, Manipur, India 2 Associate Professor, Department of Biochemistry, Jawaharlal Nehru Institute of Medical Sciences, Porompat, Imphal, Manipur, India 3Professor, Department of Medicine, Jawaharlal Nehru Institute of Medical Sciences, Porompat, Imphal East, a Manipur, India. 4Professor, Department of Biochemistry, Jawaharlal Nehru Institute of Medical Sciences, Porompat, Imphal East, Manipur, India. Corresponding Author: Sujeeta Oinam Abstract: Adenosine deaminase (ADA) is an enzyme present in most human tissues. It is also known as adenosine aminohydrolase and involved in purine metabolism. It is an important marker of inflammation. Elevation of the main serum transaminases, aspartate transaminase (AST) and alanine transaminase (ALT) levels indicates liver cell injury. Liver is the main organ that regulates carbohydrate metabolism. Diabetes mellitus is associated with increased risk of liver disease. The aims of the study is to measure serum ADA and transaminases levels in type 2 diabetes mellitus (T2DM) subjects and healthy controls. And to find out any correlation between ADA, fasting blood sugar (FBS), Glycated haemoglobin (HbA1c) and transaminases The study was carried out in 60 cases of T2DM and 30 healthy controls. Serum ADA was measured spectrophotometrically based on Guisti and Galanti method. FBS, HbA1c, ALT and AST were measured in all the study subjects.
    [Show full text]
  • The Correlation of Transaminases and Liver Diseases
    THE CORRELATION OF TRANSAMINASES AND LIVER DISEASES Bastianus Alfian Juatmadja, I Wayan Putu Sutirta Yasa, DAP Rasmika Dewi, Bagus Komang Satriyasa Department of Clinical Pathology Faculty of Medicine Udayana University / Sanglah Hospital ABSTRACT The symptoms of liver diseases are very diverging, from the mild one till the severe one. Sometimes we may find that severe heart disorders but the symptoms are too less. We need some tools to make a good diagnosis. We can not only use a good anamnesis, but also have to use good physical examination and the other support test. Transaminase also called aminotransferase. This aminotransferase catalyzes the transfer of the amino group (−NH2) of an amino acid to a carbonyl compound. The liver contains specific transaminases for the transfer of an amino group from glutamic acid to α-keto acids that correspond to most of the other amino acids. Other transaminases catalyze reactions in which an amino group is transferred from glutamic acid to other compounds. Transamination is one of the principal mechanisms for the formation of necessary amino acids in the metabolism of proteins. Transaminase as a sign to cell damage may divided into Serum Glutamic Oxalocetic Transaminase (SGOT), Serum Glutamic Pyruvic Transaminase (SGPT), and Lactic Dehydrogenase (LDH). Gamma GT and alkali fosfatase correlate with cholestasis. Cholinestrase correlate with liver synthesis capacity. Keywords: Transaminase, amino group, α-keto acids Introduction Early detection to these liver diseases is absolutely needed to decrease the morbidity and mortality. Early detection means early treatment. A good and precise treatment may decrease the diseases progressivity and may cure the diseases1.
    [Show full text]
  • COVID-19, MERS and SARS with Concomitant Liver Injury—Systematic Review of the Existing Literature
    Journal of Clinical Medicine Review COVID-19, MERS and SARS with Concomitant Liver Injury—Systematic Review of the Existing Literature 1,2,3, 4, 5 Michał Kukla y , Karolina Skonieczna-Zydecka˙ y , Katarzyna Kotfis , Dominika Maciejewska 4 , Igor Łoniewski 4, Luis. F. Lara 6, Monika Pazgan-Simon 3,7, Ewa Stachowska 4 , Mariusz Kaczmarczyk 8, Anastasios Koulaouzidis 9 and Wojciech Marlicz 10,* 1 Department of Internal Medicine and Geriatrics, Jagiellonian University Medical College, 2 Jakubowskiego St., 30-688 Cracow, Poland; [email protected] 2 Department of Endoscopy, University Hospital in Cracow, 2 Jakubowskiego St., 30-688 Cracow, Poland 3 1st Infectious Diseases Ward, Gromkowski Regional Specialist Hospital, Wroclaw, 5 Koszarowa St., 50-149 Wroclaw, Poland; [email protected] 4 Department of Human Nutrition and Metabolomics, Pomeranian Medical University in Szczecin, 71-460 Szczecin, Poland; [email protected] (K.S.-Z.);˙ [email protected] (D.M.); [email protected] (I.Ł.); [email protected] (E.S.) 5 Department of Anaesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, 70-111 Szczecin, Poland; katarzyna.kotfi[email protected] 6 Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA; [email protected] 7 Department of Infectious Diseases, Wroclaw Medical University, 5 Koszarowa St., 50-149 Wroclaw, Poland 8 Department of Clinical and Molecular Biochemistry, Pomeranian Medical University in Szczecin, 70-111 Szczecin, Poland; [email protected] 9 Centre for Liver & Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK; [email protected] 10 Department of Gastroenterology, Pomeranian Medical University, 71-252 Szczecin, Poland * Correspondence: [email protected]; Tel.: +48-91-425-3231 These authors contributed equally to this work.
    [Show full text]
  • Approach to the Patient with Abnormal Liver Biochemical and Function Tests 9/21/14, 9:09 PM
    Approach to the patient with abnormal liver biochemical and function tests 9/21/14, 9:09 PM Official reprint from UpToDate® www.uptodate.com ©2014 UpToDate® Approach to the patient with abnormal liver biochemical and function tests Author Section Editor Deputy Editor Lawrence S Friedman, MD Sanjiv Chopra, MD Anne C Travis, MD, MSc, FACG, AGAF All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Aug 2014. | This topic last updated: Nov 12, 2013. INTRODUCTION — Abnormal liver biochemical and function tests are frequently detected in asymptomatic patients since many screening blood test panels routinely include them [1]. A population-based survey in the United States conducted between 1999 and 2002 estimated that an abnormal alanine aminotransferase (ALT) was present in 8.9 percent of respondents. Although the term "liver function tests" (LFTs) is used commonly, it is imprecise since many of the tests reflecting the health of the liver are not direct measures of its function. Furthermore, the commonly used liver biochemical tests may be abnormal even in patients with a healthy liver. However, for the sake of simplicity, the abbreviation "LFTs" will be used in this discussion to denote liver biochemical and function tests in general. This topic review will provide an overview on the evaluation of patients with abnormal liver biochemical and function tests. Detailed discussions of the individual tests are presented separately. (See "Liver biochemical tests that detect injury to hepatocytes" and "Enzymatic measures of cholestasis (eg, alkaline phosphatase, 5’-nucleotidase, gamma- glutamyl transpeptidase)" and "Classification and causes of jaundice or asymptomatic hyperbilirubinemia" and "Tests of the liver's biosynthetic capacity (eg, albumin, coagulation factors, prothrombin time)".) COMMON LIVER BIOCHEMICAL AND FUNCTION TESTS — Blood tests commonly obtained to evaluate the health of the liver include liver enzyme levels, tests of hepatic synthetic function, and the serum bilirubin level.
    [Show full text]
  • Monitoring of Liver Function Tests and Hepatitis in Patients Receiving Buprenorphine/Naloxone
    PCSS Guidance Topic: Monitoring of Liver Function Tests and Hepatitis in Patients Receiving Buprenorphine (With or Without Naloxone) Original Author: Andrew J. Saxon, M.D. Last Updated: 02/26/2014 (Adam Bisaga M.D.) Guideline Coverage: This topic is also partially addressed in Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction (TIP 40), pages 33-34. http://buprenorphine.samhsa.gov/Bup%20Guidelines.pdf Clinical Questions: 1. How should I monitor liver function tests in patients with or without underlying chronic hepatitis who are receiving buprenorphine for the treatment of opioid dependence? 2. What should I do if a patient receiving buprenorphine does develop evidence of acute hepatitis or worsening chronic hepatitis? Background: Early reports of adverse events related to buprenorphine treatment raised concerns about possible hepatotoxicity as some participants showed increases in serum aminotransferase levels (Berson et al., 2001b; Lange et al., 1990). A retrospective study found that patients with a history of hepatitis (but not those without such a history) exhibited statistically significant (but not necessarily clinically meaningful) increases in ALT (median increase=8.5 IU) and AST (median increase=9.5 IU (Petry et al., 2000). In this study, higher buprenorphine doses were associated with greater odds of an increase in AST. Several case reports describe patients with Hepatitis C (HCV) who developed severe, acute hepatitis while injecting buprenorphine or taking it sublingually (Berson et al., 2001b; Herve et al., 2004; Zuin et al., 2009). Some of these patients remained on lower dose buprenorphine or were re-challenged with it without further evidence of liver injury.
    [Show full text]
  • Pharmacologic Treatments for Coronavirus Disease 2019 (COVID-19): a Review
    Clinical Review & Education JAMA | Review Pharmacologic Treatments for Coronavirus Disease 2019 (COVID-19) A Review James M. Sanders, PhD, PharmD; Marguerite L. Monogue, PharmD; Tomasz Z. Jodlowski, PharmD; James B. Cutrell, MD Viewpoint pages 1769, and IMPORTANCE The pandemic of coronavirus disease 2019 (COVID-19) caused by the novel 1767 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) presents an unprecedented Related article page 1839 challenge to identify effective drugs for prevention and treatment. Given the rapid pace of CME Quiz at scientific discovery and clinical data generated by the large number of people rapidly infected jamacmelookup.com by SARS-CoV-2, clinicians need accurate evidence regarding effective medical treatments for this infection. OBSERVATIONS No proven effective therapies for this virus currently exist. The rapidly Author Affiliations: Department of expanding knowledge regarding SARS-CoV-2 virology provides a significant number of Pharmacy, University of Texas potential drug targets. The most promising therapy is remdesivir. Remdesivir has potent in Southwestern Medical Center, Dallas vitro activity against SARS-CoV-2, but it is not US Food and Drug Administration approved (Sanders, Monogue); Division of Infectious Diseases and Geographic and currently is being tested in ongoing randomized trials. Oseltamivir has not been shown to Medicine, Department of Medicine, have efficacy, and corticosteroids are currently not recommended. Current clinical evidence University of Texas Southwestern does not support stopping angiotensin-converting enzyme inhibitors or angiotensin receptor Medical Center, Dallas (Sanders, Monogue, Cutrell); Pharmacy Service, blockers in patients with COVID-19. VA North Texas Health Care System, Dallas (Jodlowski). CONCLUSIONS AND RELEVANCE The COVID-19 pandemic represents the greatest global public health crisis of this generation and, potentially, since the pandemic Corresponding Author: James B.
    [Show full text]
  • Fatty Liver – What to Do?
    Fatty Liver – What to do? michael herman d.o. Borland-groover clinic Jacksonville, florida Liver Enzymes Liver enzymes are not liver function tests! “True” liver function tests Albumin INR Bilirubin The patient with elevated liver enzymes usually has normal liver function LAE’s (Liver Associated Enzymes) What is a normal ALT? We do not know! Normal values vary among laboratories and geographic regions Normal range 31-72 U/L ALT levels correlate with BMI Males < 30 U/L Females < 19 U/L Dutta A, et al. Hepatology 2009;50:1957-1962, Prati D, et al. Ann Intern Med 2002;137:1-9 NHANES 1999-2002 Prevalence of Elevated Transaminases in the US If defined as AST <37 or ALT <40 No hepatitis C or alcohol use ALT elevated – 7.3% Baseline elevation in AST elevated – 3.6% LFT’s Either elevated – 8.1% Prevalence of elevated liver tests was 2x higher compared to NHANES 1988-1994 Ioannou GN, et al. Am J Gastroenterol 2006;101:76-82 Is ALT a Sensitive Marker of Liver Disease? Hepatitis C viremia Historical normal values (up to 40 U/L) Sensitivity 55%, specificity 97% Updated normal values (males 30 U/L, females 19 U/L) Sensitivity 76%, specificity 89% Detection of fibrosis in NAFLD 43% of normal ALT patients had fibrosis 38% of elevated ALT patients had fibrosis Prati D, et al. Ann Intern Med 2001;137:1-9, Mofrad P, et al. Hepatology 2003;37:1286- 1292 Serum ALT in Perspective We don’t know what a normal level is It lacks sensitivity for common liver diseases Elevations may be seen in normal people Degree of elevation does not correlate with
    [Show full text]
  • Elevated Transaminases As a Predictor of Coma in a Patient with Anorexia Nervosa: a Case Report and Review of the Literature
    Elevated transaminases as a predictor of coma in a patient with anorexia nervosa: a case report and review of the literature The Harvard community has made this article openly available. Please share how this access benefits you. Your story matters Citation Yoshida, Shuhei, Masahiko Shimada, Miroslaw Kornek, Seong-Jun Kim, Katsunosuke Shimada, and Detlef Schuppan. 2010. Elevated transaminases as a predictor of coma in a patient with anorexia nervosa: a case report and review of the literature. Journal of Medical Case Reports 4: 307. Published Version doi:10.1186/1752-1947-4-307 Citable link http://nrs.harvard.edu/urn-3:HUL.InstRepos:4874829 Terms of Use This article was downloaded from Harvard University’s DASH repository, and is made available under the terms and conditions applicable to Other Posted Material, as set forth at http:// nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of- use#LAA Yoshida et al. Journal of Medical Case Reports 2010, 4:307 JOURNAL OF MEDICAL http://www.jmedicalcasereports.com/content/4/1/307 CASE REPORTS CASE REPORT Open Access Elevated transaminases as a predictor of coma in a patient with anorexia nervosa: a case report and review of the literature Shuhei Yoshida1,2*, Masahiko Shimada1,3, Miroslaw Kornek2, Seong-Jun Kim2, Katsunosuke Shimada3, Detlef Schuppan2 Abstract Introduction: Liver injury is a frequent complication associated with anorexia nervosa, and steatosis of the liver is thought to be the major underlying pathology. However, acute hepatic failure with transaminase levels over 1000 IU/mL and deep coma are very rare complications and the mechanism of pathogenesis is largely unknown.
    [Show full text]