What are ALT and AST enzymes. How do elevated levels impact liver health. When should primary care doctors be concerned about high AST ALT levels. What are the common causes of elevated liver enzymes. How to diagnose and manage patients with abnormal liver function tests.

The Significance of ALT and AST in Liver Health Assessment

Alanine Aminotransferase (ALT) and Aspartate Aminotransferase (AST) are crucial enzymes that play a vital role in assessing liver health. These enzymes are primarily found in liver cells and are released into the bloodstream when liver cells are damaged or die. Elevated levels of ALT and AST in the blood can indicate various liver conditions, making them essential markers for primary care physicians to monitor.

What is ALT and its role in liver function?

ALT, or Alanine Aminotransferase, is an enzyme that catalyzes the transfer of an amino group from alanine to alpha-ketoglutaric acid, producing glutamate and pyruvate. It is predominantly found in the liver and kidneys, with smaller amounts in the heart and skeletal muscles. ALT is considered more specific for liver damage compared to AST, as it is rarely elevated in heart or muscle diseases without liver involvement.

How does AST differ from ALT?

AST, or Aspartate Aminotransferase, is another enzyme involved in amino acid metabolism. While ALT is more liver-specific, AST is found in various tissues, including the liver, heart, skeletal muscles, and kidneys. The ratio of AST to ALT can provide valuable information about the nature and severity of liver disease.

Interpreting Elevated ALT and AST Levels in Asymptomatic Patients

When primary care physicians encounter asymptomatic patients with elevated ALT and AST levels, it’s crucial to interpret these results carefully. The degree of elevation, the ratio between AST and ALT, and the presence of other abnormal liver function tests can provide valuable insights into the underlying cause and severity of liver damage.

What are the normal ranges for ALT and AST?

The normal range for ALT is typically 14-63 IU/L, although this may vary slightly between laboratories. AST levels are generally similar to ALT in healthy adults. It’s important to note that ALT levels can fluctuate by 10-30% from day to day and up to 45% within a single day, with highest levels occurring in the afternoon and lowest at night.

How significant are mildly elevated liver enzymes?

Mild elevations of ALT and AST (less than 2-3 times the upper limit of normal) are common and may not always indicate significant liver disease. Factors such as obesity, certain medications, and non-alcoholic fatty liver disease can cause mild elevations. However, persistent elevations warrant further investigation.

Common Causes of Elevated ALT and AST Levels

Understanding the potential causes of elevated liver enzymes is crucial for primary care physicians to develop an appropriate diagnostic and management plan. Here are some common causes of elevated ALT and AST levels:

• Viral hepatitis (hepatitis A, B, C)
• Alcoholic liver disease
• Non-alcoholic fatty liver disease (NAFLD)
• Drug-induced liver injury
• Autoimmune hepatitis
• Hemochromatosis
• Wilson’s disease
• Alpha-1 antitrypsin deficiency
• Cirrhosis
• Hepatic ischemia

How do ALT and AST levels vary in different liver conditions?

The pattern of ALT and AST elevation can provide clues about the underlying liver condition:

1. Viral hepatitis: ALT is typically higher than AST, with levels 10-40 times the upper limit of normal.
2. Alcoholic hepatitis: AST is usually higher than ALT, with an AST:ALT ratio greater than 2.
3. Toxic or ischemic injury: Both ALT and AST can be extremely elevated, often more than 40 times the upper limit of normal.
4. Cirrhosis: Mild elevations (less than 2 times normal) are common, with AST often higher than ALT.
5. NAFLD: Mild to moderate elevations, typically less than 5 times the upper limit of normal.

Diagnostic Approach for Elevated ALT and AST in Asymptomatic Patients

When faced with asymptomatic patients showing elevated ALT and AST levels, primary care physicians should follow a systematic approach to diagnosis and management. This approach includes a thorough medical history, physical examination, and appropriate laboratory and imaging studies.

What initial steps should a primary care doctor take?

The first steps in evaluating elevated liver enzymes include:

1. Confirm the elevation with repeat testing
2. Review the patient’s medical history, including alcohol consumption and medication use
3. Perform a comprehensive physical examination
4. Order additional liver function tests, including bilirubin, alkaline phosphatase, and albumin
5. Consider testing for viral hepatitis, autoimmune markers, and metabolic disorders

When should imaging studies be considered?

Imaging studies such as ultrasound, CT, or MRI may be warranted if initial tests are inconclusive or if there’s suspicion of structural liver disease, fatty liver, or hepatic masses. Ultrasound is often the first-line imaging modality due to its accessibility and lack of radiation exposure.

Management Strategies for Patients with Elevated Liver Enzymes

The management of patients with elevated ALT and AST levels depends on the underlying cause and the severity of liver dysfunction. Here are some general management strategies:

• Address modifiable risk factors (e.g., alcohol cessation, weight loss for NAFLD)
• Discontinue or modify hepatotoxic medications
• Treat underlying conditions (e.g., antiviral therapy for hepatitis B or C)
• Monitor liver enzymes and function tests regularly
• Provide patient education on liver health and lifestyle modifications
• Consider referral to a hepatologist for complex cases or persistent elevations

How often should liver enzymes be monitored?

The frequency of monitoring depends on the severity of elevation and the underlying cause. For mild, unexplained elevations, retesting every 3-6 months may be appropriate. More frequent monitoring (every 1-3 months) may be necessary for patients with known liver disease or those undergoing treatment.

Special Considerations in ALT and AST Interpretation

Primary care physicians should be aware of several factors that can influence ALT and AST levels and their interpretation:

How does body mass index (BMI) affect liver enzyme levels?

A high body mass index can increase ALT levels by 40-50%. This is often related to non-alcoholic fatty liver disease, which is increasingly common in overweight and obese individuals.

What role does vitamin B6 play in ALT and AST measurements?

Both ALT and AST require vitamin B6 (pyridoxal-5′-phosphate, P5P) as a catalytic cofactor. Pyridoxal-5′-phosphate deficiency is common in alcoholic liver disease and renal failure, which can affect enzyme measurements. Some laboratories add excess P5P to their enzyme reagents to standardize measurements, but this practice is not universal.

When to Refer to a Specialist

While primary care physicians can manage many cases of mildly elevated liver enzymes, certain situations warrant referral to a hepatologist or gastroenterologist:

• Persistent unexplained elevations despite initial workup
• Evidence of advanced liver disease or cirrhosis
• ALT or AST levels more than 5 times the upper limit of normal
• Suspicion of autoimmune hepatitis or other complex liver disorders
• Need for liver biopsy or advanced imaging
• Management of chronic viral hepatitis or other specific liver diseases

How can primary care physicians collaborate with specialists?

Effective collaboration between primary care physicians and specialists is crucial for optimal patient care. This may involve:

• Clear communication of patient history and test results
• Shared decision-making regarding treatment plans
• Coordinated monitoring of liver function and treatment response
• Regular updates and follow-up between primary care and specialty care

By understanding the significance of ALT and AST levels, recognizing common causes of elevation, and following a systematic approach to diagnosis and management, primary care physicians can play a crucial role in identifying and managing liver disorders in asymptomatic patients. Early detection and appropriate management can significantly improve outcomes and prevent progression to more severe liver disease.

Alanine Aminotransferase or ALT is increased in liver disease

Alanine Aminotransferase (ALT)

Alanine aminotransferase is an enzyme involved in the transfer of an amino group from the amino acid, alanine, to alpha-ketoglutaric acid to produce glutamate and pyruvate. ALT is located primarily in liver and kidney, with lesser amounts in heart and skeletal muscle. Increased ALT activity is more specific for liver damage than increased aspartate aminotransferase (AST) activity. ALT is seldom increased in patients with heart or muscle disease in the absence of liver involvement. In healthy children, plasma ALT activity is lower than AST until 15 to 20 years of age. Thereafter, plasma ALT activity tends to be higher than AST activity until age 60, when the activities become roughly equal. The half-life of ALT in the circulation is 47 +/- 10 hours.

ALT activity in the liver is 3000 fold higher than in serum. Measurement of serum ALT activity is a good indicator of hepatocyte injury.

X ULN = times upper limit of normal, Protime prolongation is number of seconds above ULN

• The best ALT discriminant value for recognizing acute hepatic injury is 300 U/L.
• ALT increases before & peak near onset of jaundice in viral hepatitis. Activity falls slowly, an avery of 10% per day. ALT remains elevated 27 +/- 16 days.
• ALT levels fluctuate between normal and abnormal in hepatitis C. 15 to 50% of patients with chronic hepatitis C have persistently normal ALT.
• In uncomplicated alcoholic hepatitis, ALT values are almost never >10 times the upper reference limit.
• Extremely elevated ALT levels are common in toxic hepatitis and hepatic ischemia secondary to circulatory collapse and heatstroke. 90% of cases with ALT >3000 U/L are due to toxic or ischemic injury. AST is usually higher than ALT and both enzymes peak in the first 24 hours after admission. After peaking, both levels fall rapidly; AST faster than ALT.
• Peak ALT levels bear no relationship to prognosis and may fall with worsening of the patients condition. In fulminant hepatic necrosis, decreasing ALT may signify a paucity of viable hepatocytes rather than recovery.

Patients with cirrhosis, non-alcoholic steatohepatitis, cholestatic liver disease, fatty liver and hepatic neoplasm typically have slightly raised serum ALT levels (<120 IU/L). Patients with cirrhosis seldom have ALT levels higher than two times normal. Cirrhotic patients without ongoing liver injury the values may have normal values.

Other causes of elevated ALT include hemochromatosis, Wilson disease, autoimmune hepatitis, primary biliary cirrhosis, sclerosing cholangitis and alpha-1 antitrypsin deficiency. The medications most commonly associated with elevated ALT are sulfonamides, statins and isoniazid.

The ratio of AST to ALT in plasma may help in the diagnosis of some liver diseases. Most liver diseases are associated with greater elevation of ALT than AST because of the longer circulating half-life of ALT. Exceptions include alcoholic hepatitis, cirrhosis, Wilson disease and very early liver damage. In these disorders the AST to ALT ratio is generally greater than 2.

Both AST and ALT require vitamin B6 (pyridoxal-5′-phosphate, P5P) as a catalytic cofactor. Pyridoxal-5’-phosphate deficiency is common in alcoholic liver disease and renal failure.  In an attempt to standardize aminotransferase assays, the International Federation of Clinical Chemistry (IFCC) recommended that laboratories add excess P5P to their enzyme reagents so that these assay accurately measure enzyme activity independently of vitamin B6 status. Unfortunately, less than 50% of ALT assays incorporate exogenous 5P5.

In healthy individuals, ALT levels can vary 10 to 30% from one day to the next.  ALT levels can fluctuate 45% during a single day, with highest levels occurring in the afternoon and lowest levels at night.  A high body mass index can increase ALT levels by 40 to 50%. 

Reference range is 14 – 63 IU/L.

Specimen requirement is one SST tube of blood.  ALT is stable at room temperature for 3 days and refrigerated for 3 weeks.  Hemolysis causes moderate increases in ALT levels.  

Abnormal liver enzymes | Christian Healthcare Ministries

Health & Wellness

By Dr. Jacobson, D.O.

A member wrote:

I’ve been doctoring a sharp, knife-like pain and burning in my sternum area for five months. My blood work shows high liver enzymes: AST [aspartate transaminase] of 561 and ALT [alanine transaminase] of 469. I’ve never consumed alcohol, smoked or taken drugs of any sort. In the last few days, my stools have been soft and a yellowish-orange color. All other tests—CT [computed tomography], MRI [magnetic resonance imaging], MRCP [magnetic resonance cholangiopancreatography], and ultrasound of my abdomen—showed nothing. Additional blood work results were good. Can you help me please?

Dr. Jacobson’s response: I summarize the history you’ve provided as follows: mid-chest pain; recent stool changes, soft and light in color; elevated liver (hepatic) enzymes with AST slightly higher than ALT; additional normal lab work; and no unusual radiology reports.

The first concern would be to address the chest pain and to rule out the most serious and immediate threats to your health. The pain’s duration—five months—and the sharp, stabbing character as a practical matter rule out a cardiac (heart) cause. It may, or may not, be related to the bowel and liver problems you describe. Most likely, it’s coming from the rib cage and sternum area; it’s called atypical chest pain, though it’s the most common type.

The changes in stool are characteristic of someone who has a biliary system issue. Bile—which assists in the breakdown of fats—is dark green and gives the stool its brown color. Manufactured in the liver, bile is normally stored in the gallbladder. Released in response to a meal containing long-chain fats, bile moves in a duct that travels through the pancreas into the small intestines. Blockage of the bile ducts anywhere in this system can result in light-colored stools similar to your description.

Abnormal liver enzyme levels may also provide a clue as to the cause. ALT, AST and alkaline phosphatase are three of the most commonly-tested enzymes, but there are others, including bilirubin levels. The latter two are typically elevated when something outside the liver is blocking the bile system. However, if all other lab tests are normal, it’s most advantageous to look at the AST and ALT values.

You report that AST and ALT are only mildly elevated, and AST is slightly higher than ALT. In this scenario, causes that should be considered include:

• acetaminophen (generic for Tylenol) or other drug toxicity,
• autoimmune hepatitis, especially in females 30-50 years old
• non-alcoholic fatty liver disease, especially in presence of obesity, diabetes, elevated cholesterol and hypertension
• iron overload (genetic hemochromatosis)
• viral hepatitis—usually higher levels of ALT and AST in the acute stage
• ischemia (lack of blood supply to the liver)
• cirrhosis of the liver—usually from chronic alcoholism
• rhabdomyolysis (a by-product of massive muscle breakdown)
• hemolysis (breakdown of blood cells)
• Budd-Chiari syndrome (The liver veins can become blocked, preventing drainage. This syndrome can vary from extremely severe to no symptoms at all.)
• Wilson’s disease (A rare inherited disorder in which copper accumulates in the liver, brain and other organs. It may be accompanied by a brown ring, or copper deposits, along the edge of the cornea and may require a liver biopsy to diagnose).
• Other conditions outside the liver such as thyroid disease or celiac

The list of possible causes for elevated liver enzymes is long, and it can be difficult to ascertain the cause. The likely diagnosis usually becomes more apparent after standard lab tests and imaging such as you described.

As your diagnosis is still elusive, however, I would make sure that your physician(s) has taken a thorough look into possible auto-immune disorders and has considered performing a liver biopsy. The best route might be to take all of your records to a university-based hepatologist—a gastroenterologist who has sub-specialized in the study of disorders of the liver, pancreas, gallbladder and biliary tree.

References

DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 – . Record No. T316452, Abnormal Liver Function Tests – Approach to the Patient; [updated 2018 Dec 02, cited West Chester, OH, May 21, 2020]. Available here. Registration and login required.

Vagvala, S.H. and O’Connor, S.D. (2018), Imaging of abnormal liver function tests. Clinical Liver Disease, 11: 128-134. doi:10.1002/cld.704

What is astral projection? Facts and theories

Astral projection is the supposed act of going out of the body during sleep, but is it real?

Tags:

supernatural

Mysticism and psychics

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What is astral projection? This phenomenon was shown in the 2016 blockbuster “Doctor Strange” and the sequel “Doctor Strange in the Multiverse of Madness”, where the superhero has the ability to separate the physical body from the spiritual one and participate in battles. But still, astral projection is not just another trick invented by filmmakers, but a spiritual practice with a long history.

Surveys show that between 8 and 20 percent of people say they have experienced something like an out-of-body experience at some point in their lives—the feeling that the consciousness, spirit, or “astral body” is leaving the physical body. While most experiences occur during sleep or under hypnosis, some claim they can experience it simply by relaxing.

Background

The idea that people can leave their body during sleep is ancient. Countless people, from New Ageers to shamans around the world, believe that it is possible to communicate with the cosmic mind through visions and vivid dreams experienced during astral projection, also known as out-of-body experiences.

The idea of ​​astral projection comes from a 19th century mystical system called Theosophy, which states that we have seven bodies, from the lowest physical to the highest spiritual and mental bodies.

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The Theosophical Society was founded in New York in 1875 by Helena Blavatsky, who claimed to have traveled the world, studied with Tibetan gurus, contacted the dead, and learned to reach higher planes from Hindus and Buddhists.

Theosophy teaches that there are seven human bodies, the third of which is the astral. The astral body can leave the physical and etheric bodies and travel through the astral planes. Theosophy had a profound influence on artists and scientists in the 19th and early 20th centuries.

Although originally a private, quasi-religious meditation practice, like many New Age beliefs, it has become commercialized. Astral travel can become big business, and there are many books, seminars, and other materials that promise to teach people to leave their physical body and access other dimensions. But does astral projection work?

Is astral projection real?

If astral projection is real, why couldn’t science prove it?

Astral travel practitioners insist that the experience must be real because it seems so vivid and some of the experiences are similar even for people from different cultures. But it is not surprising that many people who try to experience an astral projection experience similar experiences, as they are told in advance what to expect from an astral projection.

This may be a profound experience, but the fundamental problem is that there is really no way to scientifically measure whether a person’s spirit “leaves” or “enters” the body. The simplest and best explanation for out-of-body experiences is that the person is simply fantasizing and daydreaming. Since there is no scientific evidence that consciousness can exist outside the brain, scientists reject astral projection.

Why hasn’t astral projection been scientifically proven?

Some argue that leading scientists are limited in their view of the world and refuse to even look at evidence that does not fit their narrow world view. However, in science, those who refute the prevailing theories are rewarded, not punished. Evidence of the existence of psychic powers, astral projection, or alternate dimensions would earn dissenting scientists a place in the history books, if not a Nobel Prize.

The scientific verification of astral travel should be fairly simple. For example, you can hide ten unknown objects in different places, and then ask the person to project their consciousness into each place and describe exactly what is there. Either the descriptions match or they don’t.

According to researcher Susan Blackmore, author of Out of the Body: A Study in Out-of-Body Experiences, people who claimed to have had astral experiences scored higher on measures of hypnotizability and, in several surveys, on absorption rates, a measure of a person’s ability to turn on something full attention and immerse yourself in it. People who have an out-of-body experience are more imaginative, suggestible, and fantasizing than others, although they have low levels of drug and alcohol use and no overt signs of psychopathology or mental illness.

There are other possible causes of OBEs and astral projections. In 2017, a study published by The Atlantic analyzed about 210 patients with vestibular disorders. The vestibular system in the inner ear is responsible for providing the body with a sense of balance, and problems associated with this system can lead to feelings of dizziness and disorientation. In a survey of patients, it was found that about 14% reported out-of-body experiences compared to 5% of those surveyed without any form of vestibular problems.

Although practitioners of astral projection insist that their experiences are real, all their evidence is anecdotal—in the same way, a person who takes psychostimulant substances may be sincerely convinced that he interacted with God, dead people, or angels while in changed state. Astral projection is a fun and harmless pastime that can feel profound and, in some cases, even life-changing. But there is no evidence that out-of-body experiences occur outside the body and not inside the brain.

Read Astral Exit Online (Full and Free) by Osborne Phillips

This book will teach you how to exit your body – simply, freely and safely. In this guide to astral travel, you will find a clear, step-by-step description of both simple and complex methods of working with the astral. You will learn how you can live, create, study and simply relax in the astral plane, make new friends and meet elementals – inhabitants of the astral world.

Contents:

• Preface 1

• 1 – What is the astral? 1

• 2 – Cosmos and soul 2

• 3 – Physical and astral training 4

  • Place setting 4

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• 4 – Awareness and manifestation of the astral body 5

• 5 – Fact and fiction 6

• 6 – Astral substance: strength and lightness 8

• 7 – Open communication channels 9

• 8 – Entrance to the astral light 10

• 9 – Astral travelers, astral inhabitants 12

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10 – Friends and helpers 13

• 11 – Exploring space 15

• 12 – Time and space 16

• 13 – Love and sex in the astral plane 18

• 14 – Healing in the astral plane 20

• 15 – Your astral potential 22

• 16 – Projection help 24

• 17 – Astral and animals 25

• 9000 2 18 – Light that brings protection 26

Osborne Phillips

EXIT TO THE ASTRAL

Foreword

Whoever you are, wherever you are, a wonderful life awaits you, or rather, many wonderful lives. And you don’t have to die to live them. This is part of the miracle. The opportunity to live with a sense of wonder awaits you now, at this very moment – and it is in no hurry. She is with you always.

Get out there and act!

Perhaps you spend most of your days at your desk, and your infrequent dreams are full of anticipation of a vacation and counting the money that the desired freedom will cost.

Perhaps you are a housewife who is in a secret struggle to keep the widest horizons of the imagination open for both you and your partner – until the children are older.

Or your work just involves endless trips, and you really want to finally find time to take a good look at some of the places that flashed past you and realize those fleeting impressions that somehow managed to hook you. Or maybe you’re an astronomer who doesn’t have enough of a far-off view of the affairs of cosmic glory. Maybe you are confined to a hospital bed or a wheelchair, or you are serving a prison sentence. Or maybe you are just a dreamer who wants his dreams, with all their fantastic events and incredible outcomes, to be something more than just dreams.

You are tired of wanting and waiting for freedom.

Whoever you are, let’s go free!

Another kind of freedom?

Perhaps this is another kind of freedom that you are looking for. You may have already read a number of books on religion, philosophy, psychology or the occult sciences – on any of these subjects or on all at once – and you want to be able to see what lies deeper and beyond conflicting points of view, get your own experience of interaction with the invisible, come to your own conclusions on this matter.

Is there life after death? You may have asked yourself this question as well.

What about reincarnation – does it exist, and if so, according to what rules does it exist?

What is “I”? Who am I? How did I get like this? Who and what can I become?

What help do I need? How can I provide it for myself? What help do others need? How to provide it?

And how can I solve all these problems while continuing to live the way I live now?

You can get answers to all these questions and new knowledge in the form that your life experience allows. You will understand what you learn, because all this will be in your native language – in terms and concepts that are natural to you.

This book: what is it for?

It is not the intention of this book to teach the reader any particular religious or philosophical system, although if you have knowledge of any of the systems, you can gain insight through the book regarding the fundamental truths of your system. This book is intended to initiate you into the great art of the psyche, astral projection. This art is naturally yours by birthright, since you were born as a human being.

This is as natural as the desire to live. Like sleep and dreams. As natural as the impulse of self-expression in dance, music, acting, any kind of creativity that involves the creation of an image.

This is as natural as the belief that we must somehow be able to fly without special apparatus – like we fly in dreams, when free flight gives us a feeling of deep happiness and inner fullness of life.

Your options

Discover how much you get from astral projection. It shows the reality of such things that seem transcendent for a person in terms of sensation, knowledge and understanding. It reveals the mysteries of the past and the future. It will elevate you to unimaginable heights of sexual ecstasy due to the extreme fullness of sensations at the appropriate moments. It will give you the strength and the way to know the wonders of the visible world and look into your own soul. You will discover a great potential for action, you will be able to help other people overcome seeming limitations. Astral projection will open the future for you. You will be able to experience the infinite levels and dimensions of the astral world, learn the various ways of organizing life and see territories arranged differently than our planet, potentially endless, providing an inexhaustible source of information and experience.

1

What is the astral?

Range of the astral world • Etheric vision • Your astral senses • Astral frontiers • Soul and body: built-in fuses • Astral substance: one and only • Astral whole

The astral world or plane represents a very wide spectrum of reality. In its highest manifestations, it brings us closer to supersensory perception, the highest forms of spirituality and releases the energy of thought. At its lower levels, it is so close to the physical universe that it is not easy to point out the dividing line unambiguously. It includes our astral bodies, our souls – components of the individual psyche.

Ether vision in ordinary consciousness

The lower levels of the astral world are sometimes called “ether”. Very many people can, without leaving their physical bodies at all, use “etheric vision” – the ability and power to see colors, shapes and living beings, albeit of a lower, but still astral level. With practice, you will almost certainly develop the power of this vision. This is a matter of skill. It has nothing to do with sharpness or other aspects of your physical vision. And it has nothing to do with human virtues. Sometimes people who claim to be able to see non-material beings and non-material phenomena are treated as if they were saints or extraordinarily spiritually gifted. In fact, the only virtue required to realize etheric vision is mindfulness and open-mindedness.

Definitely, the level of someone’s involvement in the astral (the ability to feel it and be aware of these sensations) is determined by the state of inner readiness. But this state can also be developed, and our possibilities increase in proportion to the knowledge of what we are striving for.

Feelings and sensations in the astral consciousness

When you are outside the limitations imposed by the body, you continue to hear, see and feel everything that surrounds you. Each manifestation of being is real and tangible at its native level. What you feel, responding to reality, is transformed by you into your usual representation – into visual images, sounds, smells, tactile sensations. If you travel astrally on the level of the material world, you will see it as it is at that very moment – if you so desire; although you will most likely want to perceive the past of the world and its possible future – that is, something that is difficult to get from ordinary, earthly travels.