Liver Enzyme Alteration

1. Liver Enzyme Alteration Angelisa B. Franceschini, MD Chairwoman Department of Pathology Universidad Central Del Caribe, School of Medicine Medical Director Laboratorios Borinquen, Inc

2. Biochemical markers of liver damage • Isolated alterations in healthy patients • Guidelines ? • Classify: hepatocellular vs. cholestatic • Initial investigation

3. Liver enzyme levels • Liver damage vs. alteration in bile flow? • Patient with symptoms or signs? • Sudden isolated unexpected finding while screening for a non-hepatic condition? • Challenge • Expensive testing • Consultation • Aim of this presentation: Provide you, pathologists, with a guide to help general physicians in the interpretation of liver enzyme alterations.

4. This is the external surface of a normal liver. The color is brown and the surface is smooth. A normal liver is about 1200 to 1600 grams. Central role carbohydrate, protein and fat metabolism. Waste products of metabolism are detoxified- amino acid deamination….urea.

5. Maintains a stable blood level of glucose: • Glycogenosis • Glycogenolysis • Gluconeogenesis • Synthesis and secretion of bile • Synthesis of lipoproteins and plasma protein, including coagulation factors. • Microscopy: acinus-(primary functional unit) • Three zones: on the basis of the distance from the supplying vessels. • Example: zone 3 - least oxygen perfusion, most mitochondria.

6. ***Edoardo G. Giannini, MD

7. Normal Ranges: How to apply reference ranges? • Performance characteristics (reproducibility, bias, total error). • Definition: a value exceeding the upper reference limit is abnormal. • Low levels has no significance • except: serum albumin. • Use your own laboratory ranges… • Remember there are patients with subclinical liver disease included. • 2.5% of “normal” patients have “abnormal” - AST or ALT • Some patients with chronic hepatitis C- 16%, non-alcoholic fatty liver-13%....with histological findings. • Age and sex limits • Activity- exercise: ↑ALT & ↑AST • Hospital patients- diet? And ↓exercise restriction- ↓

8. Fig. 1: Schematic representation of an approach to liver enzyme alteration. Specific modalities of enzymealteration (how) and their relation with peculiar characteristics of the patient and locality (whereand when) should be thoroughly assessed before the definitive diagnostic work-up is begun.

9. Where, When and How • Always ask questions…Traveling…Ethnicity • Where?Who is your patient? • Example: Bayamón, P.R. – 50%- ↑ALT (genetics?) • Wales- 60% - ↑ AST (due to ischemic or toxic liver disease). • Far East- orofecal transmittable hepatitis viruses (60%) are the major causes of sporadic acute and fulminant hepatitis.⁵ • Primary Biliary Cirrhosis 2% in Australia; .424 per 100,000 in Asia. • Homozygosity for the C282Y mutation in the HFE gene can be found in about 5/1000 people of Northern European descent but .0001/100 people of African American ethnicity.

10. When? • Timing in relation to age of the patient • Example: Wilson’s disease – early in life • Comorbid conditions should be explore • Ingestion of medications. • Date it started with relation to alterations. • Almost any medication can liver enzymes. • Herbal remedies are overlooked. • Over the counter meds. .

11. How? • First piece of evidence: Pattern. • Disease: Common causes have typical patterns… • Careful examination- • Predominant pattern- (hepatocellular vs. cholestatic) • Magnitude of alteration (<5 time, 5-10 times or >10 times); mild, moderate or marked. • Rate of change (increase or decrease over time) • The nature of the course of alteration (mild fluctuations vs. progressive)

12. Serum aminotransferace levels in various liver disease

13. Hepatocellular predominant and cholestatic predominant • Fundamental to narrowing down the differential diagnosis. • Certain liver diseases may display a mixed biochemical picture- • ↑AST and ↑ALT with mild abnormalities of alkaline phosphatase (ALP) and gamma- glutamyl transpeptidase (GGT) levels-

14. Hepatocellular predominant • AST and ALT increased: • are enzymes that catalyze the transfer of α-amino groups from aspartate and alanine to the α-keto group of ketoglutaric acid to generate oxalacetic and pyruvic acids respectively, which are important contributors to the citric acid cycle. Both enzymes require pyridoxal-5’-phosphate (vitamin B6) in order to carry out this reaction, although the effect of pyridoxal-5’-phosphate deficiency is greater on ALT activity than on that of AST. • This has clinical relevance in patients with alcoholic liver disease, in whom pyridoxal-5’-phosphate deficiency may decrease ALT serum activity and contribute to the increase in the AST/ALT ratio that is observed in these patients.

16. Hepatocellular predominance • Both aminotransferases are highly concentrated in the liver. • AST is also diffusely represented in the heart, skeletal muscle, kidneys, brain and red blood cells, and ALT has low concentrations in skeletal muscle and kidney. • An increase in ALT serum levels is, therefore, more specific for liver damage

17. Marked and moderate aminotransferace increase • > 10 times the upper reference limit: acute hepatic injury. • Data suggest that the most sensitive and specific aminotransferase threshold is within the moderate range (5-10 at 200 IU/L for AST and 300 IU/L for ALT). • The academic attribution of cause and “severity” of acute damage on the basis of magnitude of enzyme elevation may be misleading since there can be a gray areas in which a range of causes overlap. • IMP: When the enzymes were tested?

18. Schematic representation of the rate of change of aminotransferace and bilirubin levels in a patient with acute ischemic hepatitis (green and yellow) and acute viral hepatitis.(blue and orange) figure 3

19. Acute viral hepatitis: • Aminotransferase peak before jaundice appears. Greater increase in serum bilirubin. • Jaundice 70% of acute hepatitis A • Jaundice in 33-50% of acute hepatitis B infection. • Jaundice in 20-33% of cases of hepatitis C infection. LDH is altered in 50% of cases, slightly above the limits.

20. Ischemic or hypoxic liver injury • Very high levels of aminotranferase > 75x the upper limit, bilirubin is lower than 34 µmol/L and LDH very high (ALT/LDH < 1). High bilirubin and Pt prolonged- risk of failure. • Less common in acute viral hepatitis • AST peaks before ALT because of peculiar intralobular distribution. Zone 3 is more vulnerable. • It is more likely in patients with concomitant sepsis or low flow hemodinamics. • Acetaminophen induced hepatic damage 54%-16% of acute failure in UK and the USA respectively. • Alcohol induced damage- GGT/ALP ratio > 2.5: jaundice in > 60% pts. • Cohen and Kaplan - ↑AST was < 6-7 times in 98% of Pts. AST/ALT > than 1 in 92% and > 2 in 70% of cases. Physical signs may help distinguish…acute vs. chronic. • Rapidly decrease of Aminotransferase after peaking, does not have prognostic value. (Figure 3)

21. Fig. 4: Schematic, initial diagnostic algorithm for a patient presenting with mild aminotransferase abnormality. HCV = hepatitis • C virus, HBsAG = hepatitis B surface antigen, ANA = antinuclear antibodies, ASMA = anti-smooth body antibodies, LKM =liver–kidney microsomes. • Alcohol abuse and, to a lesser extent, drug-induced liver injury are frequently associated with mild aminotransferase abnormality, and their causality should be ruled out on a clinical basis. • In the western world, chronic viral hepatitis, autoimmune hepatitis and hereditary hemochromatosis are the most common causes of mild aminotransferase alteration for which specific serological tests are available. • Although nonalcoholic fatty liver disease (NAFLD) or steatohepatitis is frequently encountered in clinical practice, it remains a diagnosis of exclusion.

22. Mild increase in aminotransferase levels A minimal or mild increase in aminotransferase level is the most common biochemical alteration encountered in everyday clinical practice.

24. Nonalcoholic fatty liver disease is the most common cause of mild alteration of liver enzyme levels in the western world, and, according to the National Health and Nutritional Survey, point-prevalence is about 23% among American adults. • The biochemical picture includes mildly raised aminotransferase levels, and GGT levels can be elevated up to 3 times the upper reference value in nearly half of patients in the absence of ethanol consumption. • As with chronic viral hepatitis, an AST/ALT ratio greater than 1, which is observed in 61% of patients with advanced fibrosis and 24% of patients with no or initial fibrosis, is highly suggestive of advanced liver disease

25. Mild increase in aminotransferase Suspicion of nonalcoholic fatty liver disease is increased by the presence of conditions linked to the metabolic syndrome and insulin resistance (increased body mass index, diabetes, hyperlipemia, hypertension), although the disease may occur in patients without these associated factors.

26. All patients presenting with mild increases in aminotransferase levels should be questioned about risk factors for hepatitis B or C infection (intravenous drug use, exposure to nonsterile needles or sexual exposure to an infected person). • However, since these 2 diseases have a high prevalence worldwide and infected people may lack or underreport specific risk factors for infection, testing for HCV antibodies and hepatitis B surface antigens is advisable for all patients presenting with a mild increase in aminotransferase levels. • If the patient tests positive for HCV antibodies, then qualitative HCV RNA testing should follow.

27. Cholestatic predominance • Presentation of liver injury with a prevalent cholestatic pattern is less frequently encountered in clinical practice than the pattern of hepatocellular damage. • ALP and bilirubin levels are routinely assessed, and the level of GGT is often measured as an additional aid toward diagnosis in particular situations because of its high sensitivity but low specificity. (Dosage of AlP isoenzymes is a more complicated technique and expensive , so GGT is preferred)

28. Alkaline Phosphatase • Drug-induced liver injury may present with a cholestatic pattern (preferential increase in ALP or ALT/ALP ratio < 2), although the degree of ALP alteration is variable and may be accompanied by hyperbilirubinemia. • Commonly used drugs such as antihypertensives (e.g., angiotensin converting enzyme inhibitors) or hormones (e.g., estrogen) may cause cholestasis and can be overlooked. Liver ultrasound in these patients is often unremarkable. • Varying degrees of ALP alteration in patients with inflammatory bowel disease (most commonly ulcerative colitis) suggest the presence of primary sclerosing cholangitis, since about 70% of these cases are associated with inflammatory bowel disease. • The same biochemical abnormality observed in middle-aged women with a history of itching and autoimmune disease raises the suspicion of primary biliary cirrhosis.

29. ALP • Abnormal ALP levels may also be a sign of metastatic cancer of the liver, lymphoma or infiltrative diseases such as sarcoidosis. • In some of these situations ALP levels may be markedly elevated and the only sign of liver involvement. • Liver ultrasound examination is extremely important when the patient history is not suggestive of disease. • Patients may require liver biopsy in order to obtain a definitive diagnosis.

31. γ-Glutamyltranspeptidase • GGT is an enzyme that is present in hepatocytes and biliary epithelial cells, renal tubules, the pancreas and intestine. • The mechanisms of alteration are similar to those described for alkaline phosphatase. • GGT is a microsomal enzyme, and its activity can be induced by several drugs, such as anticonvulsants and oral contraceptives. • Elevated GGT levels can be observed in a variety of nonhepatic diseases, including chronic obstructive pulmonary disease (COPD) and renal failure. • May be present for weeks after an acute myocardial infarction.

32. GGT • Lack of specificity but high sensitivity for liver disease, GGT can be useful for identifying causes of altered ALP levels, or elevated levels, together with other biochemical abnormalities… • AST/ALT ratio > 2 may support the diagnosis of alcoholic liver disease.

34. Gilbert’s syndrome • Gilbert’s syndrome is determined by a variety of genetic defects in UDP-glucuronyltransferase that affect about 5% of the population. • In these subjects serum indirect bilirubin usually does not exceed 68 μmol/L, and the remainder of liver chemistry tests and • Liver ultrasound is unremarkable. • This condition is usually diagnosed on a clinical basis alone. • The patient should be reassured of the benign nature of this enzymatic alteration.

35. Albumin and prothrombin time assessment:Are we really testing liver function? • Determining serum albumin levels and assessing prothrombin time are often considered “tests of liver function.” • …because hepatic synthesis of albumin tends to decrease in end-stage liver disease • Increase in prothrombin time depends on the decreased synthesis of liver-derived coagulation factors., • In fact, Albumin is produced by hepatocytes, and prothrombin time depends on the activity of clotting factors I, II, V, VII and X, which are produced in the liver. • Neither test is specific for liver disease, since albumin serum levels may decrease in patients with nephrotic syndrome, malabsorption or protein-losing enteropathy, or malnutrition, and prothrombin time may be prolonged by warfarin treatment, deficiency in vitamin K (which is needed to activate clotting factors II, VII and X) and consumptive coagulopathy.

36. Conclusions • Alterations in liver enzyme levels are one of the most common problems encountered in everyday clinical practice. • Finding the way through the multiple diagnostic pathways can challenge even the experienced clinician. • Knowledge of the pathophysiology of liver enzymes is an essential guide to understanding their alteration. • The pattern of enzyme abnormality, interpreted in the context of the patient’s characteristics, can aid in directing the subsequent diagnostic work-up. • Awareness of the prevalence of determined liver disease in specific populations and of possible hepatic involvement during systemic illnesses or drug therapies may help the clinician identify the cause of alterations efficiently.