I have made it a habit to always give patients a copy of his or her bloodwork, whether we ordered it or not. All too often there are abnormal findings like elevated liver enzymes that were never discussed.
First, a brief primer on liver enzymes checked by blood work. Many doctors mistakenly call these tests, like aspartate aminotransferase (AST–formerly called SGOT), alanine aminotransferase (ALT–formerly called SGPT) and alkaline phosphatase (Alk phos), liver function tests.
They are absolutely NOT liver function tests.
Why? The reason that these liver enzymes are elevated is because liver cells are dying from injury. When they die, they spill out their enzymes into the bloodstream and levels go up. Does looking for enzymes from dead cells sound like a “functional” test?? How can looking at cells that are now dead tell how well that cell is functioning??
It’s not. There ARE functional tests for the liver that check for how well the liver is detoxifying. These tests use small amounts of aspirin, acetominophen and caffeine to check how efficiently your body is breaking down these compounds. This is truly a functional test.
That’s not to say that having your liver cells dying off is a good thing. In the past, liver damage was associated with things like viral infections (hepatits viruses), chronic alcoholism and Tylenol poisening (accidental or intentional). These were the most common reasons that we saw elevations in liver enzymes.
But with today’s poor quality, pro-diabetic lifestyles, liver damage is occuring at higher rates than ever before because of the pre-diabetic state. Make no mistake about it–prediabetes is very bad for your liver. And this can show up initially as a mild elevation in your liver enzymes EVEN WITHIN THE NORMAL LIMITS.
The first time I wrote about the association between prediabetes and elevated liver enzymes was sometime in 2001. In other words, it is not new news. Despite this, the relationship between elevated liver enzymes and prediabetes seems to have eluded mainstream medicine. This particular study just drives this point home. In it, researchers looked at 251 patients in a VA facility who had at least 2 alanine transaminase (ALT) values above 40 IU/ml that were seen in blood work taken at least 6 months apart (without any positive results for hepatitis C RNA, hepatitis B surface antigen, or screens for excess alcohol use) to see how these patients were handled by the primary care physician.
Based on the medical record, a few actions by the PCP were possible:
- Recognition of abnormal ALT levels in the record
- Mention of non-alcoholic fatty liver disease (NAFLD) as a possible diagnosis
- Recommendations for diet or exercise (an absolute must for managing prediabetes)
- Referral to a specialist for further NAFLD evaluation
Keep in mind that, based on earlier research, even mid and high normal levels of ALT have been shown to be a predictor of prediabetes, so the fact that researchers used 40 as the cut off means a huge chunk of patients were not even included. These patients also needed lifestyle recommendations or at least a warning that they are at risk.
Here’s what the researchers found:
- 39.4% had documentation in medical record notes of abnormal ALT
- 21.5% had NAFLD mentioned as a possible diagnosis
- A mere 14.7% were counseled regarding diet and exercise
- 10.4% were referred to a specialist
- Only 3% of patients at a high risk of fibrosis (NAFLD fibrosis score >0.675) were referred to specialists
The only factor that led to an increased likelihood of the PCP paying attention to the elevated liver enzymes was the magnitude of the ALT elevation (in other words, the levels had to be 80 IU/ml or above for them to take notice).
Consider this. In a small study on children diagnosed with NAFLD and followed for 20 years, there was a 1,360% likelihood of dying. This is NOT a condition that needs to be missed.