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Causes of high ast and alt: What the primary care doctor should do?


Top Causes of Elevated Liver Enzymes

Elevated liver enzymes may act as a warning that something is damaging your liver and should never be ignored. 

Learn what causes elevated liver enzymes, what symptoms you may present with and more importantly how to treat this problem…


Liver Enzyme Made Easy (AST & ALT)

What are liver enzymes and what do they mean? 

In the most simple sense liver enzymes is used to represent a series of test that can help to determine if your liver is functioning appropriately. 

The standard “liver function tests” include: 

  • Alanine Transaminase (or ALT for short): ALT is produced in the liver cells known as hepatocytes and is a very specific marker of liver cell damage.
  • Aspartate Transaminase (or AST for short): AST is not quite as specific as ALT for liver damage as it is also found in skeletal muscle, heart muscle, and kidney tissue. AST tends to rise with ALT if liver damage is present. 
  • Alkaline Phosphatase (or ALP for short): ALP is produced by the cells lining the bile ducts or the “plumbing” of the liver. A rise in ALT is commonly seen in conditions that caused blocked “ducts” such as bile stones or direct damage to the bile ducts. 
  • Gamma-glutamyl transferase (or GGT for short): GGT is found in liver, kidney, pancreatic and intestinal tissues. If GGT is elevated along with ALP this is highly indicative of an obstruction in the plumbing of the liver or may indicate gallbladder disease. 

If you are dealing with “elevated liver enzymes” you most likely have an issue with AST and ALT. 

While ALP and GGT are still important to assess what is happening in the liver most physicians refer to AST and ALT as the “liver enzymes”. 

So what do liver enzymes tell us?

Liver enzymes help us determine if there is damage to the cells of the liver or direct damage to the liver tissue itself. 

If damage is present in the liver then it will react by releasing these special enzymes (AST and ALT) into the bloodstream as the cells become “leaky”. 

So if you are dealing with an elevation in liver enzymes that is an indication that there is some sort of damage occurring in your liver. 

And this is obviously less than ideal. 

Your liver is considered a vital organ (meaning you can’t live without it) and it helps to detoxify chemicals you come into contact with, break down supplements/medications, red blood cell production, hormone production and plays a critical role in protein synthesis and biochemical reactions. 

These reactions are critical to everyday life which is why you can’t live without your liver. 

In addition, we have no way to create “synthetic” livers in the event that you have permanently damaged your liver. 

So it’s in your best interest to keep yours healthy. 

For the purposes of this article, we want to focus on the most common causes of elevated liver enzymes so that you can determine what is causing the problem and then prevent long-term and permanent damage. 

When we talk about an “elevation” in AST and ALT we really need to define what we are talking about, what kind of numbers you should be worried about and how to address them. 

The “Rise” in Liver Enzymes

There are two basic types of elevated liver enzymes:

The first is a slight or subtle increase in AST and ALT which and the second is a massive increase in AST and ALT. 

We are going to focus on the slight or subtle increase in AST and ALT (levels less than 100-300 times normal)  because this usually indicates a chronic condition that results in low-grade inflammation and damage to the liver over time. 

Massively elevated AST and ALT (levels greater than 10x the normal reference range) usually indicates an acute life-threatening condition such as liver failure from medication overdose, physical trauma to the liver or massive organ failure. 

While massive elevations in liver enzymes are obviously important, the subtle increase is more relevant to most people because they can do something about it. 

So what does it mean to have elevated liver enzymes?

Most laboratory reference ranges include a “range” of values to indicate that you are “normal”. 

If you go outside (or too high) this range then you are considered to have elevated liver enzymes. 

The standard range largely depends on the laboratory but in general, is somewhere around 0-45 IU/l for ALT and 0-30 IU/l for AST. 

If your AST and ALT are higher than the 45 and 35 then they are said to be “elevated”.

And this is a big issue because by definition that means that you are experiencing some sort of liver damage. 

More important than just knowing that your liver function tests are elevated is figuring out why they are elevated, to begin with, and the picture behind their elevation. 

We will discuss the most common causes of elevated AST and ALT below (including treatment) but first, let’s talk a little bit about lab values. 

While the laboratory data shows there is a “range” for both AST and ALT you can picture the damage done to your liver on a spectrum. 

On this spectrum, the higher your AST and ALT values are the more damage that exists in the liver. 

This correlation exists to the point that you can almost define disease states based on the elevation of AST and ALT. 

For instance: 

Patients with chronic hepatitis tend to have AST and ALT levels in the 30-120 range, those with autoimmune hepatitis tend to have levels in the 100-600 range. 

Perhaps more important than these two causes is liver damage caused by a condition known as non-alcoholic fatty liver disease. 

If your liver enzymes are elevated then there is a VERY high chance the damage to your liver is actually caused by your diet and a condition known as insulin resistance. 

The elevation in AST and ALT observed in this condition tends to be mild (and may even be missed!). 

People with non-alcoholic fatty liver disease will often have a very “modest” elevation in AST and ALT, somewhere in the 30-70 range for both. 

What’s more interesting is that people with this condition tend to be completely asymptomatic, which means that this condition is really only picked up on routine screening. 

Patients with this condition often tend to also be overweight and have issues with glucose regulation. 

Once it is identified that you do indeed have elevated liver enzymes your Doctor should begin to do a workup to figure out the cause. 

Once the cause is determined then you can focus on the treatment. 

When thinking about what causes damage to the liver it’s important to focus on those conditions which are VERY common as opposed to rare conditions. 

Most Common Causes of High AST/ALT

There are MANY, MANY conditions and disease states that lead to high AST and ALT but the majority of them can be boiled down to just a few conditions. 

This list below is not all encompassing but should give you a good idea on how to get started. 

Emphasis should be put on #1 and #2 which will most likely account for the vast majority of slight elevations in AST and ALT in most people. 

The reason you should focus on these is that they are treatable and reversible. 

#1. Non-Alcoholic Fatty Liver Disease (AST and ALT levels in the 30-70 range)

This is by far the #1 cause of elevated AST and ALT in the United States with a prevalence of up to 30% (1) and it’s primarily caused by insulin resistance and almost entirely preventable!

How it happens:

As you consume sugary, especially refined sugar, your body rapidly metabolizes glucose into fats or lipids in the liver through a process known as de novo lipogenesis. 

As the influx of glucose becomes more than your body is able to handle this fat begins to get stored in the liver. 

As fat increases in the liver, it results in damage to the liver cells. 

This damage is seen in the serum (bloodstream) as an elevation in serum levels of AST and ALT. 

If the diet is not changed or if insulin resistance is not managed then this fat accumulation will eventually cause permanent and chronic damage to the liver. 

This may result in complete liver failure over time. 

It’s very important to find out if your elevated liver enzymes are caused by non-alcoholic fatty liver disease because it can be treated and damage can be prevented. 

Those with AST and ALT caused by fatty liver disease can be diagnosed by checking AST/ALT levels in conjunction with fasting glucose, Hgb A1c, serum cholesterol and by checking the BMI. 

People who have metabolic syndrome and high AST/ALT should be evaluated for diabetes and insulin resistance. 

Treating NAFLD and High AST/ALT

If you have liver damage from insulin resistance and obesity then you should be aggressive with your treatment. 

The following therapies have been shown to reduce (and even reverse) liver damage from NAFLD: 

  • Weight Loss: Losing weight has been shown to reduce AST and ALT levels and reverse liver damage. There’s a right way to lose weight and a wrong way, so focus on improving your diet and exercising more as opposed to simply restricting your calories. 
  • Medications: Certain medications such as metformin, GLP-1 agonists, SGLT-2 inhibitors and carb blockers have been shown to reverse insulin resistance help with weight loss and improve LFT’s. 
  • Dietary Intervention: Insulin resistance is often caused by over-consumption of refined sugars and carbohydrates. You can impact insulin levels by reducing the amount of sugar and refined carbohydrates you consume (2)(bread, pasta, bagels, pizza, sugary drinks, etc.). 
  • Supplements: Certain supplements have been shown to reduce inflammation and oxidative stress which is critical in the pathogenesis of NASH and NAFLD. These supplements have been shown in studies (3) to help: Vitamin E, Vitamin C, Berberine, Probiotics, Glutathione precursors (Betaine). 
  • Exercise: Exercise helps to increase insulin sensitivity and may assist with weight loss. If you have elevated liver function tests and you are overweight make sure you don’t forget the basics like exercise. 

Treatment should then be focused on managing blood sugar, dietary changes, and specific medications/supplements. 

#2. Alcoholic Liver disease (AST and ALT in the 70-700 range)

Alcoholic liver disease used to be the #1 cause of liver failure in the United States until it was taken out by non-alcoholic fatty liver disease and obesity. 

Having said that it is still an important cause of liver damage in many people. 

The liver damage caused by alcohol consumption occurs after prolonged and excessive drinking (usually years worth of damage to the liver). 

It can occur from daily drinking or episodes of binge drinking. 

Consuming 30 grams of undiluted alcohol for 10 years (4) may result in a condition known as cirrhosis (permanent liver damage). 

The mechanism of damage is similar to that of non-alcoholic fatty liver disease. 

Overconsumption of alcohol results in direct damage to liver cells and puts an increase in demand on your body. 

You can think of alcohol as a liquid carbohydrate source that must be metabolized by the liver. 

This produces chronic damage and fat accumulation in the liver much like non-alcoholic fatty liver disease.  

What’s interesting is that alcohol consumption, even in small amounts, can make existing liver conditions (such as non-alcoholic fatty liver disease) even worse. 

Because of this, it is recommended that you stop consuming alcohol if you have elevated liver enzymes – even if it is not primarily caused by alcohol consumption.

The primary treatment for alcoholic liver damage is to stop consuming alcohol, in some cases, this is enough to completely reverse the condition or at least stop further damage. 

#3. Prescription Medications (Low-grade elevation of AST/ALT)

Certain prescription medications can also cause liver damage. 


Medications must be metabolized by the body and that metabolism usually occurs in the liver. 

As your body breaks down certain medications it creates byproducts that can still remain active and some may even be toxic. 

If these metabolites are left in the body they can cause local injury to the liver or injury to other tissues. 

The perfect example is Tylenol (5).

In small doses, your liver can metabolize it without issues, but once doses become excessive Tylenol metabolites can cause serious damage to your body and even result in acute liver failure. 

In the case of Tylenol, even daily doses of 5 to 8 grams per day may lead to liver damage over time. 

This is very important to consider because Tylenol is available over the counter and commonly used for aches and pains. 

Other medications that may cause liver damage include: 

If you are taking a medication that is causing liver damage (and it isn’t necessary to take) then the treatment is to discontinue or reduce the dosage of medication. 

#4. Certain Supplements (Low-grade elevation of AST/ALT)

Even some supplements have been shown to cause acute liver damage and cause a rise in liver function tests. 

The supplements that tend to cause issues are hard to pinpoint exactly. 

Most of the information we have stems from case studies of patients who were taking very suspect types of “fat burners” and combining them with many different weight loss supplements. 

Some case studies (10) show that these type of supplements can cause acute liver damage in certain susceptible individuals. 

This shouldn’t be enough to cause alarm among most people, however. 

The people who experience these side effects tend to do so when they use poor quality supplements that likely contain actual hormones and medications in them. 

Not all supplements are regulated in the same way that the pharmaceutical industry is, which means that you can get more (or less) than what you are expecting. 

Some weight loss supplements have even been shown to contain toxic doses of actual thyroid hormone (11).

You can avoid all of these potentially dangerous side effects simply by purchasing high-quality supplements that ship from the United States (don’t purchase supplements overseas) from reputable companies and suppliers. 

Also, please avoid supplements with “too good to be true” advertising, especially in the weight loss area. 

You can read more about how to safely and correctly use supplements such as fish oil,
berberine, and CLA to augment weight loss therapies in my other guides. 

Using these types of non-gimmicky supplements can actually help with weight loss – provided they are used correctly. 

#5. Autoimmune Hepatitis (AST/ALT in the 100 to 600 range)

While autoimmune hepatitis is not as common as the other 4 listed above it’s still worth mentioning. 

Autoimmune disease is on the rise in the United States and is, therefore, a very important cause of diseases. 

The term autoimmune means exactly as it sounds – auto attack by the immune system on your body or tissues. 

In autoimmune hepatitis (12), your immune system creates antibodies that circulate in the body and target your liver as the “enemy”. 

This results in inflammation and chronic damage which can lead to irreversible damage in some cases. 

Who is at risk for developing this condition?

It turns out, like most autoimmune diseases, that women get this disease much more frequently than men. 

What causes it?

While the exact mechanism and trigger are unknown it is felt that the etiology of autoimmune hepatitis is multifactorial. 

What this means is that the disease can be “triggered” or “turned on” by certain environmental factors such as exposure to toxins or infection. 

Autoimmune diseases tend to occur in individuals with a genetic predisposition, meaning not everyone is at risk. 

#6. Viral Hepatitis & Other Viral Diseases (AST and ALT depend on the degree of the damage)

An elevation in liver function tests will prompt an immediate workup for basic viral hepatitis by your physician. 

A history of intravenous drug use, old tattoos or high-risk behavior may increase the risk that your liver damage is caused by a viral infection. 

Hepatitis B and Hepatitis C, both of which are viral infections, may lead to chronic and long-term damage to the liver. 

Hepatitis A (13) (spread via the fecal-oral route) on the other hand tends to be more acute in nature with an acute spike in AST and ALT in a short period.  

This should be compared to chronic Hepatitis B and C (14) which tend to cause a slower and more long-term elevation in liver function tests. 

But these aren’t the only viruses that cause liver damage. 

CMV and EBV (15) (both of which are very common) may also cause an acute spike in liver enzymes. 

The damage from CMV and EBV tends to be short-lived however and shouldn’t cause long-term damage. 

In addition, the rise in liver enzymes is almost always associated with other systemic symptoms such as fatigue, malaise, sore throat (in the case of EBV) and fever.   

It’s worth mentioning viral infections because they are an important cause of liver damage, but they are generally caught and treated appropriately in most patients. 

#7. Copper and Iron Overload Syndromes (AST and ALT depend on the degree of the damage)

Another sinister cause of liver damage and thus elevated liver enzymes is an overload of certain metals in the body. 

Overload syndromes such as Iron overload (also known as hemochromatosis (16)) and copper overload (also known as Wilson’s disease (17)) result in deposition of high levels of metals in specific tissues which results in damage to these tissues over time. 

While iron and copper deposit in more than just the liver, they definitely can and do cause liver damage if they are deposited there. 

The prevalence of Hemochromatosis is estimated to be around 1 in every 200 to 500 people which are fairly high. 

Generally, those people who have Hemochromatosis are often asymptomatic and the diagnosis is made by finding a slight elevation in liver function tests with abnormal serum iron levels. 

As long as it is caught early the damage can be mitigated. 

Wilson’s disease is much less common and more difficult to diagnose but still worth mentioning as it is an overload disease that can cause liver damage. 

Tips to Naturally Treat and Improve Liver Function

Regardless of the cause of liver damage in your body, there are several steps that you can take to improve liver function and perhaps impact your liver enzyme levels. 

If you aren’t sure where to start then you can consider following these guidelines. 

And remember:

The #1 cause of elevated liver enzymes in the United States is non-alcoholic fatty liver disease which is caused by obesity and insulin resistance.  

It’s also one of the most treatable causes of liver damage. 

Find the Root Cause

Whenever possible your main goal should be to find the source and cause of your elevated liver enzymes. 

Once you know the source you can direct your treatment to that specific problem. 

For example:

The root cause of non-alcoholic fatty liver disease = insulin resistance and obesity (which should be your target treatment). 

The root cause of alcoholic fatty liver disease = alcohol intake.

The root cause of iron overload syndrome = inability to get rid of iron adequate (treatment should focus on reducing oral iron intake and phlebotomy (18)). 

You should never “ignore” elevated liver enzymes because they indicate something wrong in your body!

I also recommend keeping an eye on your AST and ALT levels with a goal to try and get both to less than 20 IU/l. 

Take inventory of Supplements and Medications

Make sure you are only taking those medications and supplements that are absolutely necessary for your body. 

Supplements AND medications must be processed through the liver which can increase demand on your body. 

Some medications you may need to continue even if they are potentially causing increase demand but the same may not be true with all supplements. 

You should also try to avoid sketchy weight loss supplements or supplements that come from overseas. 

Taking supplements such as B12, a multivitamin, fish oil, etc. should not be an issue. 

Clean Up Your Diet

That means eating more fruits and vegetables!

Even if your liver issues are not caused by insulin resistance you can bet that eating excess sugar or refined carbs will definitely NOT be helping your issue. 


Once the liver is slightly damaged it becomes susceptible to other potential causes of damage. 

If you have non-alcoholic fatty liver disease you can be sure that excess alcohol consumption is NOT going to help your liver out. 

Stick to these tips:

  • Consume plenty of fresh and whole fruits and vegetables (19) (a rich source of antioxidative vitamins like B carotene and Vitamins C & E)
  • Avoid refined carbohydrates (bread, pasta, bagels, etc.)
  • Avoid refined sugars (especially sugary drinks such as flavored coffee, and sodas)
  • Avoid alcohol 100%
  • Avoid fast food
  • Consume walnuts (a rich source of a-linoleic fatty acid)

Certain Supplements

While some supplements may potentially be damaging to the liver, others may offer considerable help. 

One such supplement is Milk Thistle. 

In various studies, milk thistle has been shown to work as an antioxidant in the liver, protect the liver against genomic injury, increase hepatocyte protein synthesis and decrease the activity of tumor promoters (20).

In animal studies (21), silymarin (the active ingredient in milk thistle) has been shown to reduce liver injury caused by Tylenol, iron overload, alcohol, and other causes. 

With this in mind, milk thistle may be considered in many individuals with elevated liver enzymes. 


Abnormalities in liver function tests should never be ignored. 

If you have been identified as having an elevation in liver enzymes then you should go to work to find the root cause. 

Whenever possible address and treat this condition and try to lower your AST and ALT levels as much as possible with treatment. 

Now I want to hear from you:

Are you suffering from an elevation of AST and ALT?

Do you know why?

Leave your comments below! 

References (Click to Expand)

#1. https://www.ncbi.nlm.nih.gov/pubmed/21875310

#2. https://www.ncbi.nlm.nih.gov/pubmed/25527677

#3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2387293/

#4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3321494/

#5. https://www.ncbi.nlm.nih.gov/pubmed/900673

#6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3983981/

#7. https://www.ncbi.nlm.nih.gov/pubmed/900673

#8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3897047/

#9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3940315/

#10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3076034/

#11. http://online.liebertpub.com/doi/abs/10.1089/thy.2013.0101?journalCode=thy&

#12. https://emedicine.medscape.com/article/172356-overview

#13. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC88961/

#14. https://www.ncbi.nlm.nih.gov/pubmed/21108341

#15. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2932915/

#16. https://www.ncbi.nlm.nih.gov/pubmed/23418762

#17. https://www.ncbi.nlm.nih.gov/pubmed/10470603

#18. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3149125/

#19. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4027841/

#20. https://www.ncbi.nlm.nih.gov/pubmed/9468229

#21. https://www.ncbi.nlm.nih.gov/pubmed/20564545

Hepatic manifestations of COVID-19 | Cleveland Clinic Journal of Medicine


Patients with COVID-19 commonly have elevated liver enzyme levels, which is associated with adverse outcomes during hospitalization including increased risk of ICU admission, intubation, and mortality. When assessing these patients, it is important to consider causes of liver injury unrelated to COVID-19. Therapies for COVID-19 may increase liver enzyme levels but are not contraindicated in patients with baseline abnormal liver tests. Liver enzymes should be regularly monitored in all hospitalized patients with COVID-19. Patients with preexisting liver disease such as cirrhosis and those who have received a liver transplant may be an increased risk of severe COVID-19 outcomes.


Physician burnout has serious consequences to the individual physician, to patients, and to healthcare institutions. Research has shown the prevalence of burnout to be more than 40%, with highest rates in frontline healthcare providers such as emergency medicine, primary care, and critical care.1 COVID-19 presents new stressors for healthcare providers, and recent events involving self-harm by physicians have brought increased attention to the emotional impacts of caring for these critically ill patients.2


Elevated liver enzyme levels can be found in 14% to 76% of patients with coronavirus disease 2019 (COVID-19).1,2 In a recent meta-analysis of 107 studies consisting of 20,874 COVID-19–positive patients, the pooled incidence of elevated liver enzymes on presentation was 23.1%.3

The pattern of liver injury is more commonly hepatocellular1 and is mild and transient in most patients.4–6 In a retrospective study of 2,273 patients with COVID-19, 45% had mild liver injury, which was defined as a levels of alanine aminotransferase (ALT) above the upper limit of normal (ULN) and below 2 times ULN.6 Liver injury was moderate (ALT between 2-5 times ULN) in 21% of cases and severe (above 5 times ULN) in 6.4% of cases.6 Severe acute hepatitis associated with COVID-19 is rare, but has been described.7

In a large retrospective study out of New York City, levels of aspartate aminotransferase (AST) were frequently higher than levels of ALT, suggesting that AST may be a useful indicator of COVID-19 infection.8 A cholestatic pattern of injury, however, is rarely associated with COVID-19.6,9 Other abnormalities in liver enzymes include elevations in gamma-glutamyl transferase (GGT), which, in one study, occurred in 13.6% of patients with COVID-19.10


Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) enters host cells by binding to angiotensin-converting enzyme-2 (ACE2), which is present in hepatocytes.1 Although a direct viral cytopathic effect is possible, limited histopathologic data have not identified SARS-CoV-2 in liver tissue.5

When evaluating COVID-19 patients with elevated liver enzymes, other etiologies should be considered including COVID-19 unrelated causes such as hepatitis A, B, and C. Ischemia,1 cardiac and muscle injury,11 and cytokine release syndrome can be associated with COVID-19 and transaminase elevations.3 In addition, other hepatic manifestations of COVID-19 have been reported. Acute portal vein thrombosis in a patient with abdominal pain, fever, jaundice, and elevated levels of transaminases has been reported and likely represents a prothrombotic state associated with the systemic inflammatory response to the virus.12 Furthermore, drug-induced liver injury (DILI) can be seen in up to 25.4% of patients with COVID-19.3 Remdesivir is associated with increased liver enzymes in about 15.2% of patients.3

The severity and pattern of liver test abnormalities have not yet been well described.13 Although a hepatocellular pattern appears to be more common,3 hyperbilirubinemia has also been described.14 Liver enzyme elevations are predominantly mild to moderate in severity and infrequently lead to treatment discontinuation.13–15 Lopinavir/ritonavir, hydroxychloroquine (less commonly), azithromycin, and tocilizumab have also been associated with abnormal AST and ALT levels in this setting.3,8 Although it is important to note that abnormal liver biochemistries are not a contraindication to using COVID-19 therapies, liver enzymes should be monitored regularly in all hospitalized COVID-19 patients.1 A summary of recommendations for the evaluation of patients with abnormal liver enzymes and COVID-19 can be found in Table 1.


Approach to elevated liver enzymes in patients with COVID-19


Liver injury appears to be more common in patients with severe COVID-193,16 and is associated with negative outcomes. In a large retrospective study of 1,059 COVID-19 patients, liver injury at presentation was an independent predictor of the composite outcome of death or intensive care unit (ICU) admissions.17 In fact, in this study, liver injury was the second most informative predictor of poor outcomes among patients with severe hypoxia.17

In another study, severe liver injury was associated with elevated levels of inflammatory markers and a more severe disease course, including higher rates of intubation, ICU admission, and mortality.6 Furthermore, an Italian retrospective study of 515 SARS-CoV-2 positive patients found that abnormal baseline liver enzyme levels were associated with an increased risk of ICU admission.10 Finally, a recently published meta-analysis of 107 studies found that patients with elevated liver enzyme levels had an increased risk of severe disease and mortality.3

Specific patterns of liver enzymes have also been shown to be negative prognostic markers. Hypoalbuminemia on admission to the hospital appears to be a marker of severe disease.6,18 In addition, peak ALT was found to be associated with death or discharge to hospice in a large US cohort study,6 while an elevated baseline AST level has been associated with ICU admission, intubation, and death in another study.8 Finally, alkaline phosphatase peak values have also been shown to correlate with the risk of death.10


Chronic liver disease

It is still unclear if patients with underlying liver disease are at higher risk of negative outcomes with COVID-19.1 Using a large US database, a study of 2,780 COVID-19–positive patients found that those with preexisting liver disease were at increased risk for mortality compared with patients without underlying liver disease. Patients with cirrhosis were at particularly increased risk (risk ratio [RR], 4.6; 95% confidence interval [CI], 2.6–8.3).19

In addition, metabolic-associated fatty liver disease (MAFLD, previously termed non-alcoholic fatty liver disease) appears to be associated with an increased risk of severe disease.1,20 In a study of 202 COVID-19–positive patients, those with MAFLD had an increased risk of severe disease and a longer viral shedding time.9 However, MAFLD is frequently associated with other comorbidities such as diabetes or cardiovascular disease, which are also established risk factors for severe COVID-19 and could contribute to worse outcomes among these patients.21

Contrary to previous findings, a recent meta-analysis showed that patients with chronic liver disease were not at higher risk of severe COVID-19.3 In this study, chronic liver disease was defined as cirrhosis of any cause, autoimmune hepatitis, chronic hepatitis B and C, and MAFLD.3 Although this was the largest systematic review published on this topic to date, the high heterogeneity among the included studies may limit the generalizability of the findings.

Liver transplantation

While early data from Italy did not show worse outcomes among liver transplant recipients22,23 more recent US data have found these patients to be at increased risk of severe COVID-19 disease,24 with a mortality rate of 29% among hospitalized patients.25 Of note, hepatitis associated with COVID-19 has been described in a living donor liver recipient on postoperative day 6. The donor was subsequently found to be SARS-CoV-2 positive.26


In summary, elevated levels of liver enzymes are often seen in patients with COVID-19 and are associated with more severe outcomes, including increased risk of ICU admission, intubation, and mortality. Other causes of liver injury should be considered when evaluating patients with COVID-19. Although COVID-19 therapies may be associated with abnormal liver tests, they may still be used in patients with elevated liver enzyme levels with close monitoring.

Emerging data suggest that patients with preexisting liver disease such as cirrhosis and those who have received a liver transplant may have an increased risk of severe COVID-19 outcomes. The American Association for the Study of Liver Diseases has released expert consensus statements to help guide management of patients with liver disease in the context of the COVID-19 pandemic.1 Selected recommendations for patients with severe liver disease are summarized in Table 2. Further research is needed to better characterize the disease course and outcomes among COVID-19 patients with chronic liver disease.


Recommendations for outpatient management of patients with decompensated cirrhosis, for liver transplant evaluations, and on a transplant waiting list during the COVID-19 pandemic


  • The statements and opinions expressed in COVID-19 Curbside Consults are based on experience and the available literature as of the date posted. While we try to regularly update this content, any offered recommendations can-not be substituted for the clinical judgment of clinicians caring for individual patients.

  • Copyright © 2020 The Cleveland Clinic Foundation. All Rights Reserved.

Liver Disease: Signs & Symptoms of Liver Failure

Last updated on 18 November 2020

The liver: A vital organ

The liver is an important organ situated in the upper part of the abdomen. It has several functions.

It is responsible for manufacturing many proteins required for the normal functioning of the body, such as proteins which enable our blood to clot when we have a cut. It manufactures bile which is important in fat digestion. The liver also helps to process and eliminate waste products and toxins from the blood stream and the body.

It is an important organ for the breakdown of chemicals including the medicines we consume. It also helps in the breakdown of red blood cells converting the haemoglobin in the red blood cells into bilirubin and which is then excreted through the bile.

Liver failure

Liver failure happens when large parts of the liver become damaged beyond repair and the liver can’t work anymore. It is a life-threatening condition that requires urgent medical care.

A failed liver is usually the final stage of many liver diseases and happens gradually, over many years. This is known as chronic liver failure. In rare cases, acute liver failure happens where the liver suddenly stops working due to causes such as ingestion of certain toxins or drugs or a viral infection.

Early symptoms include nausea, loss of appetite, fatigue, and diarrhoea. As liver failure progresses, other symptoms such as jaundice, bleeding tendency, swollen abdomen, mental confusion, and sleepiness are observed.

Liver cirrhosis is one of the most common conditions that leads to chronic liver failure. It is a condition where scar tissue gradually replace healthy liver cells leading to a damaged liver. Heavy drinking and obesity are risk factors for cirrhosis.

Signs and symptoms of liver failure

Despite the liver’s importance, patients with liver disease often do not have signs or symptoms. This is because the liver has excess functional capacity. Signs and symptoms of impaired liver function will manifest only when the liver function is reduced by more than half. These may include:

  • Jaundice (yellowing of the whites of the eyes and skin)
  • Abdominal and leg swelling
  • Drowsiness
  • Easy bruising
  • Abdominal discomfort
  • Nausea
  • Disorientation

Liver function blood tests

Very often, one discovers that the liver is not quite normal when abnormalities in the liver tests are found. While abnormalities in these tests usually mean that something is happening in the liver, none of these tests are specific for the liver and diseases outside the liver may cause changes in these tests.

Consult a gastroenterology specialist and get the appropriate tests done to understand better what is going on in your liver.

Protein and albumin levels

The protein and albumin levels reflect the ability of the liver to make proteins. A reduction in protein and albumin occurs as the liver function deteriorates and the liver is no longer able to manufacture proteins. However, protein and albumin levels may also occur in patients with severe infections or if proteins are lost in the urine or stools.

Bilirubin level

The bilirubin level reflects the liver’s ability to eliminate waste products from the body. However, high bilirubin levels may also reflect a blood disorder which causes increased breakdown of red blood cells and increased bilirubin production.

Alanine transaminase (ALT) and aspartate transaminase (AST)

The alanine transaminase and aspartate transaminase (AST) are proteins found inside liver cells. Increased levels could mean the presence of a liver disease which damages liver cells causing the release of these proteins into the bloodstream. However, AST is also found in muscles cells and may be high in patients with damage to skeletal or cardiac muscle damage.

Alkaline phosphatase

Alkaline phosphatase is an enzyme which is found in the liver and the bile ducts. Increased alkaline phosphatase often reflects the presence of either liver or bile duct disease. However, this is a protein which is also found in the bone and the intestines. Fractures and diseases affecting the bone also cause increased levels of alkaline phosphatase.

Gamma glutamyl transferase

The gamma glutamyl transferase (GGT) is an enzyme which is found in the liver and is elevated in liver diseases. It is often used in conjunction with the alkaline phosphatase to determine that an elevated alkaline phosphatase level is caused by liver disease. However, the GGT is also elevated in diseases of the bile duct and the pancreas.


The other signs and symptoms of liver disease occur only when the liver starts to fail and is unable to carry out its function. This often occurs only late in the course of disease. The most famous sign of liver disease is jaundice, where the white of the eyes and the skin turn yellow. This is caused by an accumulation of bilirubin in the body because the liver can no longer eliminate it as it begins to fail.

Jaundice may be acute and temporary, as in the case of acute hepatitis A infection, where the liver damage is transient and the jaundice will reverse once the liver recovers. However, in patients with chronic liver disease where there is ongoing and continuing damage, such as hepatitis B and alcohol induced liver disease, the jaundice may persist for a longer period of time.

Abdominal and leg swelling

A patient whose liver fails will accumulate fluid in the abdomen and in the legs. The leg swelling often starts in the feet and more of the legs will become affected when the function of the liver worsens and fluid accumulation increases. Abdominal swelling is often not obvious initially. However, as it becomes worse, the patient’s abdomen will become more prominent and the umbilicus may also start turning outwards.


The liver plays an important role in removing chemicals and toxins from the bloodstream. These may be produced by the bacteria in our gut which is then absorbed into the bloodstream, or they may be produced when the body breaks down cells and proteins. As the liver function deteriorates, the liver is unable to remove toxins from the bloodstream quickly enough. High concentrations of toxins like ammonia can affect the brain which will cause drowsiness. This is known as hepatic encephalopathy.

Easy bruising

The liver manufactures some of the proteins important for blood clotting. In patients with chronic liver disease whose liver function is deteriorating, the liver’s ability to make these blood clotting proteins is also reduced. Patients will then bleed more easily resulting in bruises forming with even minor trauma.

Abdominal discomfort

Abdominal discomfort is an uncommon symptom in patients with liver disease. The liver tissue itself does not have any nerve endings and so very often no pain or discomfort is experienced. However, nerve endings are found in the capsule surrounding the liver and when the liver swells up very quickly, stretching of this capsule may result in discomfort or pain in the upper abdomen. An example of this would be the swelling of the liver in patients with acute hepatitis A.

None of the blood test abnormalities, symptoms or signs are specific for liver disease. Should one have any suspicion that the liver is abnormal, the family doctor should be consulted and appropriate tests done. Appropriate referrals can then be made should these suspicions be true.

Causes of chronic liver disease

The most common causes of chronic liver disease include:

  • Hepatitis B
  • Hepatitis C
  • Heavy alcohol consumption
  • Non-alcoholic fatty liver disease

Other causes, which are less commonly seen are:

  • Paracetamol overdose, which can damage the liver or lead to failure
  • Reactions to certain prescription or herbal medications
  • Eating poisonous wild mushrooms called Amanita phalloides
  • Industrial toxins including carbon tetrachloride, a cleaner and degreaser
  • Hemochromatosis is an inherited disorder that causes iron build up in the liver


Article reviewed by Dr Ling Khoon Lin, gastroenterologist at Mount Elizabeth Hospital


What is Liver Failure? (n.d) Retrieved October 27, 2020, from https://www.webmd.com/digestive-disorders/digestive-diseases-liver-failure#1

Cirrhosis and Your Liver (n.d) Retrieved October 27, 2020, from https://www.webmd.com/digestive-disorders/understanding-cirrhosis-basic-information#1

Care of the Patient With Abnormal Liver Test Results


Yale University School of Medicine, New Haven, Connecticut

CME Objective: To review current evidence for evaluation, management, practice improvement, and education of patients with abnormal liver test results.

Funding Source: American College of Physicians.

Disclosures: Dr. Tran, ACP Contributing Author, reports no disclosures of interest. Dr. Lim, ACP Contributing Author, reports research contracts from Allergan, Conatus Pharmaceuticals, GENFIT, Gilead, and Intercept Pharmaceuticals and unpaid leadership roles with the American Association for the Study of Liver Diseases, the American Gastroenterological Association, and the American College of Gastroenterology. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M21-0988.

Editors’ Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Stephanie Chang, MD, MPH, Deputy Editor, reports employment with the Agency for Healthcare Research and Quality, travel compensation from the Guidelines International Network, and participation in the Patient-Centered Outcomes Research Institute methodology committee. Vineet Chopra, MD, MSc, Deputy Editor, reports grants received from the Agency for Healthcare Research and Quality and royalties from UpToDate and Oxford University Press. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interests to disclose. Eliseo Guallar, MD, MPH, DrPH, Deputy Editor, Statistics, reports that he has no financial relationships or interests to disclose. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center and consultancy with Boston Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports employment with the Perelman School of Medicine, University of Pennsylvania, and consultancies with the U.S. Food and Drug Administration and the State of Colorado.

With the assistance of additional physician writers, the editors of Annals of Internal Medicine develop In the Clinic using MKSAP and other resources of the American College of Physicians. The patient information page was written by Monica Lizarraga from the Patient and Interprofessional Partnership Initiative at the American College of Physicians.

In the Clinic does not necessarily represent official ACP clinical policy. For ACP clinical guidelines, please go to https://www.acponline.org/clinical_information/guidelines/.

This article was published at Annals.org on 14 September 2021.

Liver Function Tests • LITFL • CCC Investigations

Overall analysis of Liver Function Tests (LFT)

Transaminitis: Aminotransferases (AST, ALT)

  • Generally associated with hepatocellular damage
  • Generally not associated with cholestasis
  • Ratio of AST and ALT can be useful in differential
  • ALT is more specific for liver damage than AST
  • AST: ALT =1
    • Associated with ischaemia (CCF and ischaemic necrosis and hepatitis)
  • AST: ALT >2.5
    • Associated with Alcoholic hepatitis
    • Alcohol induced deficiency of pyridoxal phosphate
  • AST: ALT <1
    • High rise in ALT specific for Hepatocellular damage
    • Paracetamol OD with hepatocellular necrosis
    • Viral hepatitis, ischaemic necrosis, toxic hepatitis

Elevation with cholestasis (ALP, GGT)

  • ALP – primarily associated with cholestasis and malignant hepatic infiltration
    • Marker of rapid bone turnover and extensive bony metastasis
  • GGT – sensitive to alcohol ingestion
    • Marker of hepatocellular damage but non-specific
    • Sharpest rise associated with biliary and hepatic obstruction
Aspartate aminotransferase (AST)

Aspartate aminotransferase (AST) catalyses conversion of nitrogenous portion of amino acid. It is essential to energy production in Krebs cycle.

  • AST is released into serum in proportion to cellular damage and most elevated in acute phase of cellular necrosis.
  • Found in decreasing levels in: (Relatively low organ specificity)
    • Liver, cardiac, skeletal muscle, kidney, brain, pancreas, red blood cells
  • Useful in the detection and differential diagnosis of hepatic disease
    • Monitor patients with cardiac and hepatic disease – levels are dependent on stage of disease

AST Levels below are for the peak of disease

  • Serum level >20 x normal
    • Severe skeletal muscle trauma
    • Acute viral hepatitis
    • Toxic hepatitis (Drug induced hepatic injury)
    • Ischaemic hepatitis (Severe passive liver congestion (CCF))
  • Serum level 10-20 times normal
    • CVS (Severe myocardial infarction)
    • Infection (Infectious mononucleosis)
    • Liver (Alcoholic cirrhosis)
  • Serum level 5-10 times normal
    • Liver (Chronic hepatitis)
    • Skeletal muscle
      • Duchenne muscular dystrophy (DMD)
      • dermatomyositis
      • influenza B calf myositis in children
  • Serum levels 2-5 times normal
    • blood (haemolytic anaemia, haemolysis)
    • liver (fatty liver, metastatic hepatic tumour)
    • other:
      • pulmonary embolus, alcoholic delirium tremens, acute pancreatitis, IM injection, strenuous physical exercise
    • drugs
      • opiates, erythromycin, sulphonamides, anti-tubercular
      • large doses of paracetamol, aspirin, vitamin A
Alanine aminotransferase (ALT)

Alanine aminotransferase (ALT) catalyses reversible amine group transfer in Krebs cycle.

  • Unlike AST, it is mainly in liver cells and is a relatively specific indicator of hepatocellular damage. It is released early in liver damage and remain elevated for weeks

Interpretation of ALT levels

** Levels are NOT related to degree of liver cell necrosis

** Absolute value is of NO prognostic significance

  • Very high serum ALT
    • hepatocellular injury
    • usually associated with much lower rise in AST
    • AST: ALT <1
      • Viral hepatitis
      • Severe toxic hepatitis
      • Ischaemic hepatitis (Shock, hypotension, CCF)
  • Moderate to high levels of ALT
    • infection – Infectious mononucleosis
    • liver – Chronic hepatitis and intrahepatic cholestasis
    • cardiac –Severe hepatic congestion in cardiac failure
    • other – Acute passage of gallstone
  • Slight to moderate increase in ALT
    • usually associated with much higher rise in AST
    • AST: ALT ratio >2.5
    • classically associated with alcoholic liver disease
      • liver: acute hepatocellular injury
      • alcoholic hepatitis
      • active cirrhosis
  • Drugs causing elevation in ALT
    • paracetamol overdose (AST and ALT)
    • phenothiazines, chlorpromazine
    • barbiturates
    • tetracycline, isoniazid, nitrofurantoin
    • morphine, codeine (Increasing intrabiliary pressure) (AST and ALT)
Alkaline phosphatase (ALP)

Alkaline phosphatase is actually up to 60 different isoenzymes, collectively measured as ALP. Electrophoresis is required to determine the exact type elevated – especially if isolated elevation

  • ALP Influence: Bone calcification and lipid and metabolite transport
  • ALP is produced by
    • Bile canalicular membrane of hepatocytes
    • Bone, placenta, small intestine
  • Elevated ALP is often associated with biliary obstruction with cholestasis – and usually before a rise in bilirubin

Interpretation of ALP levels

  • Causes of an increased ALP
    • Liver (usually indicates cholestasis or obstruction) – Sensitive indicator of mild biliary obstruction
      • Hepatic tumour (SOL)
      • Viral hepatitis
      • Infectious mononucleosis
    • Pregnancy (non-pathological) – Released to serum from placenta in late pregnancy
    • Bone (usually non-pathological in children)
      • osteomalacia
      • bone metastasis
      • Paget’s disease of bone
      • deficiency induced rickets
      • adolescents and children with rapid bone growth
    • Blood type O and B (non-pathological) – released form small intestine after fatty meal
  • Commonest causes of a marked rise in ALP
    • Complete biliary obstruction
    • Extensive bone metastases – pancreatic associated with isolated ALP rise (no ALT)
    • Hyperparathyroidism
  • Causes of isolated rise in ALP
    • CCF (Often associated with AST and ALT rise)
    • Hodgkin’s
    • IBD
    • Diabetes
    • Hyperthyroidism
  • Causes of a low ALP
    • Hypomagnesaemia, HYPOphosphatemia
    • Protein deficiency
Gamma glutamyl transferase (GGT)

Gamma glutamyl transferase (GGT) is associated with transfer of amino acids across cell membranes

  • GGT is produced in the renal tubules, liver, biliary tract, pancreas, lymphocytes, brain, testes
  • GGT is most useful when looking for hepatocellular damage
    • More sensitive than ALP and AST – but much less specific
    • Particularly sensitive to effects of alcohol on liver
    • Increased production of GGT as ductal enzymosis, with increased enzymes produced in response to hepatocellular damage

Increased levels of serum GGT

  • Liver
    • Response to any Hepatocellular injury
    • Following alcohol ingestion (No necessity for Hepatocellular damage)
  • Other
    • Pancreatitis, Brain tumours, Renal disease, Prostatic disease
    • Cardiac disease (Increase 5-10 days after AMI)

Rapid increase in GGT

  • Obstructive jaundice
  • Hepatic metastatic infiltration (usually with obstruction)
Lactate Dehydrogenase (LDH)

Lactate dehydrogenase (LDH) catalyses the reversible conversion of lactic acid to pyruvic acid. The final step in Embden–Meyerhof–Parnas pathway, providing bridge to Krebs cycle and thus cellular energy

  • LDH is most useful in monitoring injury heart, liver, lung, hematological disorders
  • It is found in most body tissues and includes 5 main isoenzymes which can be helpful diagnostically
    • LD1 and LD2 – Heart, RBC, kidneys
    • LD3 – Lungs
    • LD4 and LD5 – Liver and skeletal muscle

Increased LDH

  • CVS (LD 1 and 2) – AMI +/- hepatic congestion
    • Rheumatic carditis, Myocarditis, CCF, Shock
  • Respiratory (LD3)
    • Pulmonary embolus and infarction
  • Haematological (LD 1 and 2)
    • Pernicious anaemia, Haemolytic anaemia, Sickle cell anaemia
  • Hepatobiliary (LD5)
    • Hepatitis, Active cirrhosis, Hepatic congestion

Emergency physician MA (Oxon) MBChB (Edin) FACEM FFSEM with a passion for rugby; medical history; medical education; and asynchronous learning #FOAMed evangelist. Co-founder and CTO of Life in the Fast lane | Eponyms | Books | Twitter |


90,000 reasons for the increase and decrease in indicators

Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) are enzymes that are present in the cells of many organs and tissues. Most of them are concentrated in the liver. The rate of ALT and AST in children of different ages is slightly different. An increase in these indicators is most often associated with diseases of the hepatobiliary system, but there are other reasons as well.

Norms of ALT and AST in children under one year old and older

The enzymes ALT and AST are synthesized inside cells and are involved in the exchange of amino acids.They enter the bloodstream in limited quantities. Increased indicators in biochemical analysis indicate the destruction of liver cells or other organs.

Normal AST levels in children under 12 months of age are up to 36 U / L. After a year – up to 31 U / l. The ALT rate is slightly different, namely:

  • in children 1–12 months – up to 27 U / l;
  • in children over 1 year old – up to 22 U / l.

Children have no gender differences. In adult men, the normal values ​​are higher.

Reasons for the increase in indicators

If a child has significantly increased levels of both enzymes, massive death of liver cells can be suspected. This happens when:

  • viral hepatitis A, B, C;
  • poisoning;
  • progressive liver tumors;
  • cirrhosis.

Indicators increased by 5-10 units are often associated with the intake of toxic medications, such as antibiotics.

If only the ALT level is elevated in the child, then, most likely, there are problems with the hepatobiliary system. Less likely causes include:

  • acute anoxia;
  • heart failure;
  • muscular dystrophy;
  • myocardial infarction;
  • severe pancreatitis;
  • severe burns.

An increase in AST levels with normal ALT levels is not always associated with liver problems.It happens:

  • for inflammatory pathologies of the myocardium and heart muscles;
  • heart attack;
  • dermatomyositis;
  • hypothyroidism;
  • intestinal obstruction.

Less commonly, it indicates cirrhosis, acute hepatitis, liver metastases. In adult women, the level of aspartate aminotransferase increases during pregnancy.

Other causes of deviations from the norm include:

  • Increase in glucose levels in diabetes mellitus;
  • hormonal disruptions;
  • high cholesterol;
  • 90,011 obesity;

  • lingering stress;
  • improper nutrition;
  • helminthiasis.

In chronic hepatitis B and C, transaminases remain within the reference values ​​or slightly increase.

Exceeding the norm of ALT and AST in children is due to many reasons

Pathologies in which the level of enzymes decreases

A decrease in the level of transaminases in the blood is less common. AST and ALT below the norm are observed:

  • with a lack of vitamin B6;
  • renal failure;
  • reduced concentration of pyridoxal phosphate, a coenzyme of aminotransferases.

Sometimes the deviation is associated with a decrease in the number of cells synthesizing enzymes, for example, with extensive organ necrosis, chronic hepatitis.

Preparation for research

Blood sampling is performed in the morning on an empty stomach. 2-3 days before visiting the laboratory, you should refrain from eating heavy foods: fatty, fried, foods containing a large amount of sugar, and taking medications.

The level of AST and ALT is influenced by the intake of the following drugs:

  • isoniazid;
  • furosemide;
  • cyanokite;
  • sulfasalazine;
  • sulfapyridine;
  • calcium dobesylate;
  • doxycycline.

Fluoride and citrate inhibit the enzyme action. It is undesirable to use such tools prior to analysis.

Additional examination

Biochemical analysis data are not enough to make a diagnosis. Often these indicators remain within the normal range in case of serious violations or slightly increase against the background of complete well-being. The need for further examination is determined depending on the situation. It is recommended to continue it in the presence of complaints and poor heredity.

If liver pathology is suspected:

  • Ultrasound of the abdominal organs;
  • clinical blood test;
  • Laboratory tests evaluating albumin and bilirubin levels.

If the child has signs of heart problems, an ultrasound and electrocardiogram (ECG) is done. To assess coagulation, a coagulogram is performed.

To diagnose renal disorders, a general urinalysis is taken, the creatinine level is assessed, the paired organ is examined using ultrasound and X-ray with contrast.

The list of additional studies includes:

  1. sugar analysis to exclude diabetes mellitus;
  2. Screening for viral hepatitis. In the presence of antibodies to infection, additional diagnostic methods are prescribed;
  3. scraping for enterobiasis to identify parasites;
  4. fibroscan to assess the degree of fibrosis;
  5. liver biopsy – if cancer is suspected.

Self-deciphering of test results is not very informative, since when assessing indicators, not only their value is taken into account, but also the ratio.


Minor ALT and AST deviations in babies under one year old do not always indicate the disease. With a strong increase in indicators, it is worth continuing the examination and finding out the cause, since early diagnosis and treatment help to solve most problems before complications develop.


See also: the rate of ALT and AST in women

High ALT – Question to the gastroenterologist

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Tests for Epstein-Barr virus – price in St. Petersburg, donate blood for analysis at SZCDM

Epstein-Barr virus (hereinafter – EBV), officially – Human gammaherpesvirus 4, is one of the 8 types of herpes viruses known to science and, with a high probability, the most widespread human virus.

For example, in the United States, more than 90% of adults and 50% of children have signs of EBV infection.American doctors believe that the remaining 10% of adults are simply not examined. In Russia, doctors determine the level of infection of the adult population at 97%.

Doctors assume that the entire adult population of the earth is infected with the virus, because it is transmitted extremely simply – with saliva (when kissing, using shared utensils, sneezing, when you share food that you have already bitten off) and genital secretions, and remains in the body until the end of life … Cases of transmission of the virus with blood during blood transfusion and household blood-to-blood contact have been identified.

A special case is organ transplant infection. Due to the spread of transplantation, such infections are becoming more common and cause atypical complications and diseases after transplantation.

In most people, EBV is “stored” in cells in a latent form and is activated under favorable conditions – a critical decrease in immunity, stress, another disease, etc. But often reactivation occurs for no apparent reason – scientists have yet to identify its causes.

The danger of the virus is that in its active form it becomes the cause of infectious mononucleosis, is associated with the occurrence of Burkitt’s lymphoma, hemophagocytic lymphohistiocytosis, Hodgkin’s lymphoma, stomach cancer, nasopharyngeal cancer, central nervous system lymphoma, Alice in Wonderland syndrome (impaired perception), acute cerebellar ataxia (violation of gait, movement).

According to the data obtained by the doctors of the Cincinnati Children’s Hospital Medical Center – Cincinnati Medical Center (USA), EBV can cause the development of multiple sclerosis, celiac disease, systemic lupus erythematosus, type I diabetes, juvenile idiopathic arthritis, rheumatoid arthritis.Even a person’s chronic fatigue is directly related to him.

Go to analyzes

Indications for analysis

Most people get the virus asymptomatically or with mild symptoms that pass quickly. The body develops a stable immunity to the virus, and a person lives with the virus “conserved” in the cell for all his life.

But EBV testing is often necessary to distinguish one infection from another and to prescribe effective treatment.The virus “disguises itself” as ARVI, hepatitis, sore throat with a persistently high temperature (up to 10% of all cases of sore throat), in which the lymph nodes are enlarged. In most cases, EBV causes infectious mononucleosis. The infection is especially reactive in adolescents and under the age of 5 years, and in boys it passes in an acute form 2 times more often than in girls.

Symptoms of infection with gradual development:

  • the state of health worsens;

  • the temperature rises to subfebrile levels – 37.1-38.0 ° C;

  • catarrhal symptoms appear – swelling of the nose and nasopharynx, congestion, the nasopharyngeal mucosa becomes red, the palatine tonsils also turn red;

  • lymph nodes – submandibular, on the back of the head, neck) edematous, at an early stage – not painful or with mild painful sensations.

Symptoms of infection in acute onset of the disease:

  • a sharp rise in temperature to 38-39 ° C;

  • fever with chills and increased sweating;

  • headache;

  • skeletal muscle pain;

  • sore throat when swallowing;

  • enlarged lymph nodes.

The infected have an enlarged spleen and liver, and a rash appears on days 3-5. Sometimes an enlarged spleen ruptures.

However, there is no single, characteristic symptomatology – scientists have combined signs of infection into a “mononucleosis-like syndrome”. Therefore, for any manifestation, it is necessary to pass tests to detect the virus.

Epstein-Barr virus tests

Referral for tests is given by a therapist, infectious disease specialist, general practitioner, pediatrician.The study is carried out on various biomaterials – blood serum, smears and scrapings of the mucous membrane of the oropharynx, urogenital tract, saliva, cerebrospinal fluid, peripheral blood leukocytes.

Serologic tests are most often done to detect infection. However, complex testing is often required, because serological tests in cases of blood transfusion, immunodeficiency and some others contradict each other. An accurate clinical picture in difficult cases is provided by PCR diagnostics for EBV DNA.

The virus is determined only by laboratory methods, and in most cases several tests are required to exclude other infectious diseases.

Complete blood count for Epstein-Barr virus

A complete blood count does not accurately establish EBV. Determination of leukocytosis, lymphocytosis, atypical mononuclear cells indicates only the presence of an infectious disease, but does not allow it to be identified.However, if the absence of leukocytosis is determined, then it is safe to say that there is no infectious mononucleosis. Other signs against EBV diagnosis are anemia and thrombocytopenia.

If a complete blood count raises suspicions of EBV, additional tests are done.

Biochemical analysis

In a biochemical analysis, when infected with EBV, the following is observed:

  • an increase in ALT, or alanine aminotransferase, an enzyme of the liver, kidneys, pancreas;

  • an increase in AST, or aspartate aminotransferase, an enzyme predominantly of heart and liver cells;

  • increased alkaline phosphatase, or alkaline phosphatase;

  • increased bilirubin – the main component of bile;

  • decrease in neutrophils;

  • decrease in platelets.

Changes in the biochemical parameters of the liver are characteristic for 90% of those infected.

Heterophilic test

The heterophilic test, or the Paul and Bunnel reaction, is based on the determination of anti-sheep agglutinins in the blood serum. The test detects heterophilic antibodies, and at a titer of 1: 224, a diagnosis of mononucleosis is made.

The heterophilic test gives a positive result in 60% of those infected 2 weeks after the detection of symptoms and in 90% of those infected one month after the first clinical manifestations.Therefore, its accuracy is low, and at the initial stage it does not help determine EBV, since the titer of heterophilic bodies also increases in response to another viral infection.

The sensitivity of the test in children is less than 70%, and the ability to identify the virus is less than 20%. As patients age, the benefit of the test and its sensitivity / specificity increase.

Serological tests

The vital activity of EBV in the body (completed and incomplete lytic (active) cycle, latent phase) occurs against the background of the production of specific antibodies to virus proteins.The study of antibodies allows you to determine and differentiate the acute form, the previous infection and the chronic infection with the virus.

In the early stages (3-4 weeks after infection and up to 3-4 months after), IgG immunoglobulins to early EA antigens are determined – they are considered markers of the acute stage of infection, although they are often detected in chronic infection.

Immunoglobulins IgG to VCA – capsid protein – are determined at the time of the onset of the disease and are considered markers of the acute stage of the disease.They disappear after a few weeks. However, there are people in whom VCA-IgM is not determined, therefore complex testing is always necessary.

The EBNA IgG antigen is not detected at the initial stage of the disease, therefore it indicates a past or chronic infection. The latter has a high antigen titer.

PCR diagnostics

PCR diagnostics refers to highly sensitive tests for EBV infection.For its implementation, the leukocyte fraction of the blood is used.

If the DNA of the virus is detected in the blood plasma, then an active infection is diagnosed. The DNA of the virus is detected even during the latent phase in people recognized as clinically healthy – 0.1–1 copies / 106 cells. Chronic and acute stages are detected by quantitative PCR.

If the viral load is high, it can be associated with a greater risk of severe complications and requires antiviral therapy.DNA in the cerebrospinal fluid says that the virus is actively multiplying in the nervous system – this PCR diagnosis of EBV is carried out when the etiology of damage to the nervous system is detected.

PCR is performed when tumors and severe complications are detected. In this case, the DNA of the virus is found in the lymph nodes, intestinal mucosa, liver biopsies. PCR is also necessary for diseases that have arisen after organ transplantation.

However, a negative result of PCR diagnostics does not exclude replication of the virus in the lymph nodes, bone marrow, dermis, stomach and intestines.Therefore, PCR is always recommended to be used in combination with serological methods for diagnosing EBV.

Prevention and recommendations

It is almost impossible not to get infected with EBV in the modern world. To do this, it would be necessary to exclude all contact with people, and from birth, not kiss anyone, not engage in sexual relations.

Paradoxically, it is better if the infection occurs in childhood, because children are easier to tolerate the infection (like, for example, chickenpox, also caused by herpesvirus, only 3 types), they develop strong immunity.

Infection in childhood is typical for countries with a low standard of living, in adolescents and adults – with a high standard of living. The role of sanitary culture, the general culture of people. But it also leads to more serious consequences of infection, because the immune response of a person living in favorable conditions is much weaker.

Only immunity can protect us from the Epstein-Barr virus. Once in the body, it remains in us until the end of life in a latent phase.A decrease in immunity caused by diseases, lifestyle leads to reactivation of EBV and unpredictable consequences – scientists have so far only managed to identify diseases associated with the virus (which we talked about at the beginning), but not to establish the pattern of their development.

Infection against EBV also does not exist. You can protect yourself at least from re-infection, without kissing, without using other people’s dishes, food, toothbrushes and other personal belongings.

If any symptoms of the disease appear, you should consult a doctor or come to the laboratory yourself to be tested for EBV.

If an infection is detected (acute phase), then you need to refuse to go to work, visit public places, because you become a spread of infection, ensure yourself peace, plenty of drink, and eat well. If severe symptoms occur, you should immediately consult a doctor – symptomatic treatment and supportive therapy will be prescribed.

In ordinary life, strengthening the immune system – sports, a healthy lifestyle, refusal from the daily use of disinfectants, for example – alcohol gels, antibacterial soaps and the like – will become a good prevention.Your immune system needs to be stressed daily to “stay fit” and your immune response is high.

Cost of testing for the Epstein-Barr virus at SZDCM JSC

At SZDTSM JSC you can pass all tests to determine VEB at a low price. Since diagnostics in most cases requires comprehensive testing, research in medical centers and laboratory terminals of SZDTSM JSC will not become financially burdensome for you – the cost of services in our medical institutions is available for all categories of the population.

Our specialist doctors will prescribe you only the necessary tests that will allow you to make an accurate diagnosis. The first study and a general blood test can be done without a doctor’s prescription, but the subsequent (if there are suspicions), we recommend doing only as directed, so as not to carry out tests that are useless in your case.

Where to get tested for the Epstein-Barr virus

You can hand over any analyzes for EBV in our medical centers and laboratory terminals.You can choose the medical facility closest to you by the map, table or drop-down menu.

Next to the name of the medical facility, you will see the exact address, opening hours, and on the map it is easy to draw up a route to visit the laboratory by public transport or private car.

90,000 ALT and AST increased during pregnancy: reasons for high rates

During the gestation of a baby, the woman’s body experiences great stress, therefore, it is often observed that the level of ALT and AST is increased during pregnancy.This phenomenon occurs even with a negative test for hepatitis. Various abnormalities in the liver can be caused by squeezing, which intensifies as the fetus grows. If changes are detected in the biochemical analysis, it is required to undergo a full examination before the moment of delivery.

Reasons for changes in indicators in the blood test

Up to 12 weeks, every woman is obliged to undergo a complete examination, which includes donating blood to detect various diseases.ALT and AST (alanine aminotransferase and aspartate aminotransferase) readings show liver function. Their increase may indicate the development of a serious pathology, even if the symptoms are completely absent. Although the analysis is normal at the beginning of pregnancy, the liver enzyme can increase at any time. Most often, this phenomenon occurs at the end of the second or beginning of the third trimester.

This phenomenon is due to:

  • By fetal pressure on the liver, which – in turn – leads to disruption of the normal functioning of the organ.
  • Increased stress on the body and exposure to large amounts of hormones.
  • Taking certain medications to maintain pregnancy.
  • Stagnation of bile due to compression of internal organs.
  • Development of hepatosis against the background of bearing an infant (hepatosis of pregnant women).

If liver enzymes are elevated during pregnancy, this may indicate that the body cannot cope with the load. A critical condition requires immediate delivery, as there is a great threat to the life of the mother and child.In case of a stable condition of the expectant mother, treatment in a hospital is prescribed.

Clinical manifestations

Elevated ALT is usually associated with the development of liver disease, biliary tract or intoxication of the body. An increased load on the mother’s body can provoke problems during pregnancy. AST rises when taking a number of medications, including those of herbal origin.

Until the moment of analysis, a pregnant woman may suspect deviations from the norm for health reasons.

During pregnancy, a number of the following clinical manifestations can be observed:

  • loss of appetite,
  • abnormal abdominal pain,
  • nausea and vomiting,
  • jaundice,
  • Stool Violation,
  • weakness,
  • itching of the skin,
  • bleeding disorders,
  • stomach dyspepsia,
  • increased gassing.

In the presence of such symptoms, the doctor must prescribe a biochemical blood test for a pregnant woman.If elevated rates are found, immediate treatment is required. After a while, a second analysis is taken to monitor the woman’s health.

From excessive stress during pregnancy, the liver can declare itself at any time.

In the absence of hepatitis, the following are assigned:

  • correction of the diet;
  • Cancellation of medicines that could provoke a worsening of the condition;
  • droppers to support the mother’s body.

As soon as uncharacteristic symptoms of ailments begin to appear during pregnancy, you should immediately inform your doctor. The body may not be able to cope with the load, which will be seen on a blood test.


Problems with the liver or gallbladder can occur at any stage of gestation, most often this phenomenon occurs in the later stages, when the internal organs are strongly clamped by the growing uterus. Elevated levels of ALT and AST are found in women who have never suffered from diseases of internal organs.

If increased indicators are found, the specialist must send the woman for additional examinations in order to exclude:

  • cholecystitis,
  • hepatitis,
  • cirrhosis.

Manifestations of hepatosis in pregnant women can increase the intake of a vitamin complex and unhealthy diet, as well as overweight.

If no serious pathologies in the work of internal organs were detected, then the specialist makes the following appointments:

  1. Correction of nutrition with the abolition of fatty, fried, reducing animal products and increasing plant foods.
  2. Cancellation of medications, taking vitamins, herbal herbs, which have caused the deterioration of the functioning of internal organs.
  3. Appointment of enzymatic preparations, droppers.

With pathologies that do not threaten the life of the mother and child, it is possible to maintain the pregnancy until the end of the term. In a later period, a woman may be saved due to elevated ALT and AST, since the condition of the fetus can worsen at any time. With hepatitis, specialists try to hold out the pregnancy until the optimal safe period in order to carry out an emergency delivery.The method of delivery is selected depending on the mother’s condition. Since elevated ALT and AST can lead to a violation of blood clotting, it will be extremely dangerous to perform a cesarean section; first, treatment and restoration of coagulability are required.

If a problem is detected early, specialists will try to do everything possible to maintain the pregnancy. Hepatosis of pregnant women is treated by adjusting nutrition and constant monitoring of the condition of the woman and the fetus.