Comprehensive Guide to Normal Range for AST and ALT: High, Low & Normal Results, Symptoms & Causes
What is the normal range for AST and ALT. Understand high, low and normal results, symptoms and causes related to AST and ALT levels in cats.
Understanding AST and ALT Levels in Cats
Biochemical analysis of a cat’s blood is one of the most informative methods for diagnosing the state of the animal’s body. It allows veterinarians to identify pathologies that cannot be determined visually or through other examination techniques. The network of veterinary clinics “Svoi Doktor” in Moscow offers this service at competitive prices, providing a detailed analysis within 12 hours to a day.
The Role of Key Enzymes
The functioning of a cat’s body involves a continuous chain of chemical reactions, with various enzymes playing a crucial role. The most active enzymes include:
- ALT (alanine aminotransferase) – Involved in amino acid metabolism. Normal level: 10 – 80 units/liter. Increased levels indicate liver toxicity, heart failure, shock, or trauma, while decreased levels can signify cirrhosis, liver necrosis, or vitamin B6 deficiency.
- AST (aspartate aminotransferase) – Responsible for the transfer of amino groups within cells. Normal range: 10 – 80 units/liter. Exceeding the normal range can indicate hepatitis, pancreatitis, physical overwork, or heart failure, while a low level may suggest a severe course of any disease or liver rupture.
- CPK or CK (creatine phosphokinase) – Involved in the processes occurring in the heart, muscles, and thyroid gland. Normal level: 150 to 798 units/liter.
- ALP (alkaline phosphatase) – Plays an important role in metabolic processes. Standard range: 39 to 55 units/liter. Increased levels can indicate bone disease, hyperparathyroidism, lymphogranulomatosis, liver problems, or vitamin C overdose, while decreased levels may be associated with anemia, zinc, magnesium, vitamin C, or B12 deficiency.
- Alpha-amylase – A digestive enzyme produced by the pancreas. Normal level: 580 – 1720 units/liter. Increased levels can suggest pancreatitis or other pancreatic diseases, acute peritonitis, or kidney problems.
Understanding Other Biochemical Parameters
Deviations from the norm in various other biochemical parameters can also provide valuable insights into a cat’s health:
- Urea – Normal range: 6 – 12 mmol/liter. Excess indicates heart failure, kidney disease, impaired urine outflow, oncology, shock, or intestinal obstruction, while decreased levels below the minimum can signify liver problems or poisoning with toxic substances.
- Creatinine – Standard range: 40 – 130 µmol/liter. Increased levels suggest renal insufficiency or hyperthyroidism, while decreased levels may indicate malnutrition and loss of muscle mass.
- Phosphorus – Normal range: 1.1 – 2.3 mmol/liter. Excess can indicate bone destruction, kidney disease, acidosis, or cirrhosis, while decreased levels may be associated with rickets, periodontal disease, hypercalcemia, hyperparathyroidism, or hyperinsulinemia.
- Calcium – Normal range: 2 – 2.7 mmol/liter. Increased levels can suggest cancer, dehydration, or kidney failure, while decreased levels may indicate rickets, osteodystrophy, pancreatitis, or liver disease.
- Total Protein – Normal range: 54 – 77 g/liter. Excess can indicate an acute infectious disease, oncology, or dehydration, while decreased levels below the standard range may be associated with pancreatitis, liver, intestinal, or kidney diseases, or cancer.
Importance of Accurate Biochemical Analysis
Biochemical analysis of a cat’s blood should be performed strictly on an empty stomach to ensure the accuracy of the results. The employees of the “Svoi Doktor” laboratory are certified specialists who use modern equipment and follow strict protocols, ensuring high-quality diagnostics. The biomaterial is taken from a vein using sterile instruments, and if the cat is calm, the owner can hold it during the procedure. If the cat is likely to break out, it is fixed on its side for the safety of both the animal and the personnel.
Importance of Veterinary Consultation
After the biochemical analysis, it is crucial to consult with a veterinarian to interpret the results and determine the appropriate course of action. The deviations from the norm in various biochemical parameters can provide valuable insights into the cat’s health, allowing the veterinarian to quickly diagnose the underlying condition and prescribe the necessary treatment. The biochemical analysis can also help determine if the cat’s diet is suitable for its nutritional needs.
Conclusion
Biochemical analysis of a cat’s blood is a crucial diagnostic tool that can help identify underlying health issues that may not be readily apparent through other examination methods. By understanding the normal ranges and the implications of deviations in key enzymes and other biochemical parameters, pet owners and veterinarians can work together to ensure the optimal health and well-being of their feline companions.
Biochemical analysis of blood in cats at low prices in Moscow
Price list
Biochemistry is one of the most informative methods for diagnosing the state of the body. It allows you to identify pathologies that cannot be determined visually, using palpation or other methods.
It is possible to take biomaterial around the clock and evaluate the parameters of blood biochemistry in a cat at the best price in the laboratory of the network of veterinary clinics “Svoi Doktor”. Our experts in the shortest possible time (from 12 hours to a day) will give a full detailed conclusion. This will help the veterinarian to quickly diagnose the disease and prescribe adequate treatment. With this analysis, you can also determine if the diet is suitable for your pet.
Scientists have long established the numerical values of indicators of various chemical elements and compounds in the blood, corresponding to the vital activity of a healthy organism.
The deviation of quantitative coefficients from the norm indicates the presence of certain problems. It is these discrepancies that allow the veterinarian to determine the presence and degree of pathology.
The functioning of all systems of the animal’s body implies a continuous chain of chemical reactions occurring as a result of the interaction of various enzymes. The most active enzymes are:
- ALT (alanine aminotransferase) – takes part in amino acid metabolism. Normal level 10 – 80 (unit/liter):
- increased levels – liver toxicity of any etiology, heart failure, shock, trauma,
- decrease – cirrhosis or necrosis of the liver, lack of vitamin B6;
- AST (aspartate aminotransferase) – causes the transfer of amino groups within cells. Norm 10 – 80 (unit / l):
- exceeding the indicator – hepatitis, pancreatitis, physical overwork, heart failure,
- low level – severe course of the disease (any), liver rupture;
- CPK or CK (creatine phosphokinase) – is involved in the processes occurring in the heart, muscles, thyroid gland.
The normal level is 150 to 798 units/litre; - ALP (alkaline phosphatase) – plays an important role in metabolic processes. Standard from 39up to 55 (u/l):
- increase – bone disease, hyperparathyroidism, lymphogranulomatosis, liver problems, tumor of the biliary tract, pulmonary or kidney infarction, vitamin C overdose,
- decrease – anemia, deficiency of zinc, magnesium, vitamin C, B12;
- Alpha-amylase is a digestive enzyme produced by the pancreas. Normal level 580 – 1720 (u/l):
- increase – pancreatitis or other pancreatic diseases, acute peritonitis, kidney problems.
The normal level is 150 to 798 units/litre;What do deviations from the norm of some other biochemical parameters show:
- urea – norm 6 – 12 (mmol / liter):
- excess indicates heart failure, kidney disease, impaired urine outflow, oncology, shock, intestinal obstruction,
- decrease below the minimum level – violation of the liver, poisoning with toxic substances;
- creatinine – standard numbers 40 – 130 (µmol / l):
- magnification indicates renal insufficiency, hyperthyroidism,
- reduction – malnutrition and loss of muscle mass;
- phosphorus – norm 1. 1 – 2.3 (mmol / l):
- excess indicates bone destruction, kidney disease, acidosis (blood acid-base imbalance), cirrhosis,
- decrease – about rickets, periodontal disease, hypercalcemia, hyperparathyroidism, hyperinsulinemia;
- calcium – normal range 2 – 2.7 (mmol/l):
- increase may indicate cancer, dehydration, kidney failure,
- decrease – for rickets, osteodystrophy, pancreatitis, liver disease;
- total protein (total concentration of albumin and globulin fractions) – the norm is 54 – 77 (g / l):
- excess indicates an acute infectious disease, oncology, dehydration,
- decrease below the standard range – about pancreatitis, diseases of the liver, intestines, kidneys, cancer, fasting.
1 – 2.3 (mmol / l):For more information about your pet’s health problems, visit your veterinarian after a vein biochemistry test.
Biochemical analysis of blood in cats is performed strictly on an empty stomach.
The accuracy of the results depends on many factors. Among them are the quality of the reagents used, the temperature regime, accounting for statistical errors, etc. The employees of our laboratory are certified specialists, and the research is carried out using modern equipment. Therefore, you can be sure of the high accuracy of our diagnostics.
Biomaterial is taken from a vein with sterile instruments. If the animal behaves calmly, then it is enough if the owner holds it during the procedure. If there is a chance that the cat will break out, then it is fixed on its side so that it does not injure the doctor. The puncture area is shaved from wool. As a rule, this is the front paw. For diagnosis, 1 ml of venous blood is sufficient. After manipulation, the paw is tightly bandaged. You can remove the bandage after 1 – 1.5 hours.
The sample is sent to the laboratory. After carrying out all the necessary studies, the formalized result will be provided to the attending physician.
Biomaterial sampling implies compliance with certain rules. Otherwise, the information about the analyzed indicators will be incorrect and may lead to the appointment of treatment that is ineffective in a particular case.
Preparation
What you need to do to donate blood biochemistry to a cat correctly:
- do not feed the animal 8 hours before the clinic visit;
- do not exercise excessively 2 days before the study;
- tell your doctor if your pet is taking any medication. Perhaps the specialist will cancel the drug for several days or adjust its dosage.
How much does blood biochemistry cost for a cat depends on the number of parameters studied. The following research options are possible:
- selective – in this case, certain elements are evaluated that are of interest to the doctor in a particular situation;
- complex (profile) – a complex of elements is analyzed in order to identify the state of functioning of a certain body system. For example, this may be the diagnosis of renal, hepatic or cardiac parameters.
For example, this may be the diagnosis of renal, hepatic or cardiac parameters.The price of laboratory diagnostics is increased by 50% if the result is required urgently (cito).
Cost of services
| Name of services | Standard deadlines* | Price for 1 study | Price Cito +50% |
| HEMATOLOGY AND HEMOPARASITES | |||
| CBC BASIC (A + automatic leuco formula) | 12-24 hours | 550 | 825 |
| CBC STANDARD (A+L+ESR) | 12-24 hours | 900 | 1350 |
| CBC ADVANCED (CBC+RTC+ESR) | 12-24 hours | 1000 | 1500 |
| AUTOMATIC CELL COUNTING (A) without leukoformula | 12-24 hours | 500 | 750 |
| ESR | 12-24 hours | 220 | 330 |
| RETICULOCYTES (RTC) | 12-24 hours | 450 | 675 |
| LEUKOFORMULA (L) | 12-24 h | 350 | 525 |
| BABESIOSIS 1 (peripheral blood smear) | 3-6 h | 550 | 825 |
| BABESIOSIS 2 (automatic + test tube blood smear for babesiosis) | 3-6 h | 750 | 1125 |
| DIROFILARIOSIS COMPLEX (Knott + IC method) | Up to 24 hours | 2000 | 3000 |
| DIROFILARIOSIS DIAGNOSIS (Knott method) | Up to 24 hours | 800 | 1200 |
| Dirofilaria immitis (Express) | 1 hour | 1500 | no |
| Cytoparasitic complex (A + mycoELISA + chlamyELISA) | up to 5 days | 2200 | no |
| Blood typing in dogs and cats | 3-6 h | 2200 | no |
| Blood compatibility | 1 hour | 550 | 825 |
| PRIMARY EXAMINATION (8 indicators: Total protein, Glucose, AST, ALT, Total bilirubin, Urea, Creatinine, Alkaline phosphatase) | 12-24 hours | 1000 | 1500 |
OPTIMUM MINI (13 indicators: Total protein, Albumin, Globulin, Glucose, AST. , ALT, Total bilirubin, Direct bilirubin, Urea, Creatinine, Alkaline phosphatase, Cholesterol) | 12-24 hours | 1500 | 2250 |
| OPTIMAL (18 indicators: Total protein, Albumin, Globulin, Glucose, AST., ALT, Total bilirubin, Direct bilirubin, Urea, Creatinine, Alkaline phosphatase, Cholesterol, P, Ca i, K, Na, Cl) | 12-24 hours | 1800 | 2700 |
| MAXIMUM (25 indicators: Total protein, Albumin, Globulin, Glucose, LDH, Amylase, AST., ALT, Total bilirubin, Direct bilirubin, Urea, Creatinine, Alkaline phosphatase, GGT, Cholesterol, CPK, P, Ca , Ca i, K, Na, Fe, Mg, Cl, triglycerides) | 12-24 hours | 3000 | 4500 |
| RENAL (13 indicators: Total protein, Albumin, Globulin, Glucose, Urea, Creatinine, P, Ca, Ca i, K, Na, Mg, Cl,) | 12-24 hours | 1250 | 1875 |
LIVER (13 indicators: Total protein, Albumin, Globulin, Glucose, AST. , ALT, Total bilirubin, Direct bilirubin, Urea, Alkaline phosphatase, GGT, Cholesterol, Triglycerides) | 12-24 hours | 1250 | 1875 |
| SURGICAL (14 indicators: Total protein, Albumin, Globulin, Glucose, AST, ALT, Total bilirubin, Urea, Creatinine, Alkaline phosphatase, Ca i, K, Na, Cl) | 12-24 hours | 1500 | 2250 |
| ELDERLY ANIMAL (13 indicators + T4: Total protein, Albumin, Globulin, Glucose, AST., ALT, Total bilirubin, Direct bilirubin, Urea, Creatinine, Alkaline phosphatase, Cholesterol) | 12-24 hours | 2500 | 3750 |
| PREOPERATIVE COMPLEX (Surgical+A+Coagulogram) | 12-24 h | 2800 | 4200 |
| CARDIAC (12 indicators: LDH, AST., ALT, Urea, Creatinine, CPK, Ca, Ca i, K, Na, Mg, Cl) | 12-24 hours | 1250 | 1875 |
EasyStat Blood gases and electrolytes ( Na+, K+, Cl-, PH, PCO2, HCO3-, tCO2, Anion gap. ) | 1 hour | 1650 | 2475 |
| BIOCHEMISTRY | |||
| IONIC COMPOSITION (Na+K+Cl+iCa) | 12-24 hours | 450 | 675 |
| Selected indicators: urine, creat, ob.bil, ave.bill, AST, ALT, ALP, GGT, LDH, glitch, ob.bel, alb, glob, cholest, Ca, P, Fe, Mg, triglycerides | 12-24 hours | 190 | 285 |
| Selected indicators : Amylase, CPK, Lipase | 12-24 hours | 400 | 600 |
| LIPASE, PANCREATIC (species-specific) | 12-24 hours | 2550 | 3825 |
| Canine CRP Express | until 12 noon | 1600 | no |
| Express Feline Serum Amyliod A (C-reactive protein) | until 12 noon | 1600 | no |
| Express Cat/Canine Brain Natriuretic Propeptide (NT-proBNP) | until 12 noon | 2200 | no |
| SDMA | until 12 noon | 2500 | 3750 |
| Troponin | until 12 noon | 2200 | 3300 |
| Fructosamine | 12-24 hours | 450 | 675 |
| Ammonia | 12-24 hours | 700 | 1050 |
| COAGULOGRAM | |||
| Coagulogram (APTT, prothrombin time, thrombin time, fibrinogen) | 12-24 hours | 1700 | 2550 |
| DIAGNOSTIC COMPLEXES | |||
| DISPENSERIZATION OF DOGS (Optimal mini+Automatic+General urinalysis+I/g complex and protozoa+Dirofillariasis Knott method) | 12-24 hours | 3300 | no |
| CAT DISPENSERIZATION (Optimal mini+Automatic+Complete urinalysis+I/g complex and protozoa) | 12-24 hours | 3000 | no |
| ENDOCRINOLOGY: ELISA*** | |||
ELISA. T4 | up to 5 days | 1400 | no |
| Express T4 | until 12 noon | 1700 | no |
| T3 ELISA | up to 5 days | 1400 | no |
| Canine TSH ELISA | up to 5 days | 1400 | no |
| Express TSH | until 12 noon | 1700 | no |
| triple T3+T4+TTG | up to 5 days | 3300 | no |
| T4 free ELISA | up to 5 days | 1400 | no |
| ELISA. Cortisol | up to 5 days | 1400 | no |
| Express Cortisol | until 12 noon | 1700 | no |
| Luteinizing hormone | up to 5 days | 1400 | no |
| Estradiol | up to 5 days | 1400 | no |
ELISA. Progesterone | 12-24 hours | 1700 | no |
| Progesterone Express | until 12 noon | 1700 | no |
| Testosterone | up to 5 days | 1400 | no |
| Small/Large Dexamethasone Sample | up to 5 days | 2500 | no |
| Express D-Dimer | until 12 noon | 1900 | no |
| DERMATOLOGY | |||
| Dermatophytes (wool microscopy) | 12-24 hours | 700 | 1050 |
| Ectoparasite scraping (deep skin scraping) | 12-24 hours | 700 | 1050 |
| Dermatological complex (wool microscopy + deep skin scraping) | 12-24 hours | 1100 | 1650 |
| Otodectosis swab | 12-24 hours | 700 | 1050 |
| Imprint smear with microscopy of stained slide | 12-24 hours | 700 | 1050 |
| Wool microscopy + ringworm culture without antimycotic susceptibility | 14-21 days | 1550 | no |
| Ringworm culture without antimycotic susceptibility | 14-21 days | 1000 | no |
CYTOLOG. RESEARCH. AFFECTED AREA (deep scraping) | 3-5 days | 1100 | no |
| URINE | |||
| Urinalysis, incl. sediment microscopy | 12-24 hours | 800 | 1200 |
| Urine protein to creatinine ratio | 12-24 hours | 400 | 600 |
| COMPLEX (URI + Bel/Crea) | 12-24 hours | 1000 | 1500 |
| Nephrocomplex (URI TCA + Gram stain) | 3-5 days | 1500 | no |
| Urinary cortisol to creatinine ratio | 3-5 days | 1100 | 1650 |
| Gram stain | 3-5 days | 800 | no |
| REPRODUCTION | |||
| Mating day determinations (Progesterone+Vaginal Pap Cytology) | 12-24 hours | 2200 | 3300 |
| COPROLOGY | |||
| I/G+PROTOSE COMPLEX (native smear+Fülleborn flotation method) | 12-24 hours | 800 | 1200 |
| GENERAL fecal analysis (including i/g and protozoa by native smear method) | 12-24 hours | 1100 | 1650 |
| ELISA | |||
| MYCOPLASMOS IgG with TITER | up to 5 days | 1400 | no |
| CHLAMYDIOSIS IgG with TITER | up to 5 days | 1400 | no |
| TOXOPLASMOSIS IgG with TITER | up to 5 days | 1400 | no |
| CORONAVIRUS IgG with TITER | up to 5 days | 2200 | no |
| LEUKEMIA ELISA with TITER | up to 5 days | 2200 | no |
| ELISA ELISA with TITER | up to 5 days | 2200 | no |
| Detection of IgG immunoglobulins for parvovirus, distemper and adenovirus (hepatitis) (with Titer) (DOGS) | up to 5 days | 2800 | no |
| CALYCIVIROSIS, HERPES, PANLEUCOPENIA with Titer (CATS) | up to 5 days | 2800 | no |
| IHA | |||
| Dogs | |||
| Parvovirus infection of carnivores (Ag) | 12-24 hours | 1100 | no |
| Canine distemper (Ag) | 12-24 hours | 1100 | no |
| Canine coronavirus (Ag) | 12-24 hours | 1100 | no |
| Influenza (CIV h4 Ag) | 12-24 h | 1350 | no |
| Adenovirus (CAV Ag) | 12-24 hours | 1350 | no |
| Borreliosis (Ab) – Lyme | 12-24 hours | 1350 | no |
| 4-D: Anaplasmosis, Dirofilariasis, Borreliosis, Ehrlichiosis | 12-24 hours | 2200 | no |
| Cats | |||
| Feline panleukopenia (Ag) | 12-24 hours | 1100 | no |
| Feline coronavirus (Ag) | 12-24 hours | 1350 | no |
| Feline Coronavirus (Ab) – Feline Viral Peritonitis | 12-24 hours | 1350 | no |
| Feline leukemia virus (Ag) | 12-24 hours | 1100 | no |
| Feline immunodeficiency virus (Ag) | 12-24 hours | 1100 | no |
| General | |||
| Dirofilariasis (Ag) | 12-24 hours | 1500 | no |
| Leishmaniasis (Ab) | 12-24 hours | 1500 | no |
| Ehrlichiosis (Ab) | 12-24 hours | 1500 | no |
| Giardiasis (Ag) | 12-24 hours | 1100 | no |
| PATHOMORPHOLOGY | |||
| POINT STUDY IMPRINT SCRAPING | 3-5 days | 1200 | no |
| FLUID | 3-5 days | 1200 | no |
| SYNOVIAL FLUID | 3-5 days | 1200 | no |
| BLOOD CYTOLOGY | 3-5 days | 1200 | no |
| TRANSUDATE AND EXSUDATE STUDY | 3-5 days | 1600 | no |
| VAGINA CYTOLOGY (pathomorphology) | 3-5 days | 1200 | no |
| PATHOMORPHOLOGY LABOCLEAN | |||
| Histological examination by a Russian pathologist (tumors – up to two locations, endoscopic/punch biopsies – up to 3 locations) – new | 7 – 10 days | 2800 | no |
| Histological examination by a Russian pathologist (tumors – more than two locations, endoscopic/punch biopsies – more than 3 locations) – new | 7 – 10 days | 3900 | no |
| Histological examination by a Russian pathologist (consultation on ready-made histological preparations) Issued only by our doctor at the appointment | 3 – 5 days | 2000 | no |
| Cytology | 1 – 3 days | 1700 | no |
| Cytology of effusion (including evaluation of cytosis) | 1 – 3 days | 1700 | no |
| Cytology of skin scrapings/smears | 1 – 3 days | 1700 | no |
| Vaginal cytology | 1 – 3 days | 1700 | no |
| Synovial fluid cytology (no cytosis/protein assessment) | 1 – 3 days | 1700 | no |
| Tracheal/bronchoalveolar lavage cytology | 1 – 3 days | 1700 | no |
| Urine cytology (Gram stain) | 1 – 3 days | 1700 | no |
| Bone marrow cytology | 1 – 3 days | 3500 | no |
Additional staining of preparations with supplemented pathologist’s report (toluidine blue, CHIC, etc. ) | 5 – 7 days | 1100 | no |
| Histological examination of foreign pathologists (tumors – up to two locations, endoscopic/punch biopsies – up to 3 locations) | 7 – 10 days | 6000 | no |
| Histological examination of foreign pathologists (tumors – more than two locations, endoscopic/punch biopsies – more than 3 locations) | 7 – 10 days | 7200 | no |
| * The timing of the analysis is indicated from the moment the courier arrives at the laboratory **- Cito- the analysis is performed within 3 hours after the arrival of the courier, the price of the analysis increases by 50% | |||
How to interpret ALT, AST, Bilirubin, Alkaline Phosphatase Tests
The American College of Gastroenterology (ACG) has issued updated guidelines for blood chemistry tests used to assess liver health
The new guidelines are aimed at both specialists and primary care physicians.
This document provides specific values for the normal range of alanine aminotransferase (ALT) levels, as well as stepwise screening algorithms for elevations in ALT, aspartic aminotransferase (AST), alkaline phosphatase, and bilirubin. In comparison with the documents of previous editions, the new recommendations contain reduced limits of the norm. Those. previous recommendations have considered upper limit values (URL) as the norm, which can vary significantly between laboratories, ranging from 30-40 international units (IU) per liter in some institutions and up to 70-80 IU/l in others. According to the new guidelines, the normal range for ALT will be 19-25 IU/L for women and 29-33 IU/L for men.
Cirrhosis of the liver. Questions and Answers
The authors noted that they are aware that due to the decrease in the limits of the norm, many patients will fall into the category with elevated indicators and that this will create certain difficulties for doctors.
However, the authors consider it justified to use lower starting points, pointing out that sometimes even the smallest level of ALT elevation significantly increases the risk of death due to liver disease.
The authors point out that elevated ALT helps identify people with chronic liver diseases such as non-alcoholic fatty liver disease and chronic hepatitis C and B. over time, its level does not return to normal. The authors hope that, over time, practitioners will become accustomed to these new levels, and this will lead to improved liver health for all, as well as general health.
Key recommendations
- Before starting to evaluate liver function abnormalities, repeat the laboratory panel and/or perform a clarifying test (eg, GGT test if serum alkaline phosphatase is elevated) to confirm that the blood chemistry for liver actually are not normal. (Strong recommendation, very low level of evidence).
- Chronic hepatitis C testing is done with anti-HCV and confirmed with HCV RNA by nucleic acid testing. Risk factors for hepatitis C include a history of intranasal or intravenous drug use, tattoos, piercings, blood transfusions, and high-risk sexual behavior. Also at risk are people born between 1945 and 1965. Testing for acute hepatitis C is done with anti-HCV and HCV RNA by nucleic acid testing. (Strong recommendation, very low level of evidence).
- Chronic hepatitis B testing is done with HBsAg testing. Testing for acute hepatitis B is associated with HBsAg and anti-HBc IgM.
The following groups are most at risk: people born in endemic or hyperendemic areas (HBsAg prevalence > 2%), men who have sex with men, ever injecting drug users, dialysis patients, HIV-infected individuals, pregnant women and family members, family members and sexual contacts of HBV-infected persons. (Strong recommendation, very low level of evidence). - Testing for acute hepatitis A (IgM HAV) should occur in patients with acute hepatitis and suspected fecal-oral exposure. Acute hepatitis E (IgM HEV) testing should also be done in those returning from endemic areas who test negative for acute hepatitis A, B, and C. (Strong recommendation, very low level of evidence).
- Patients with elevated BMI and other features of the metabolic syndrome, including diabetes mellitus, overweight or obesity, hyperlipidemia, or hypertension with mild ALT elevations, should undergo ultrasound screening for non-alcoholic fatty liver disease (NAFLD). (Strong recommendation, very low level of evidence).
- Women consuming more than 140 g of alcohol per week or men consuming more than 210 g per week who have AST > ALT should be considered at risk for alcoholic liver disease and should be advised to stop drinking alcohol. (Strong recommendation, very low level of evidence).
- All patients with abnormal liver function tests in the absence of acute hepatitis should be tested for hereditary hemochromatosis with iron, transferrin, and serum ferritin levels. HFE mutation analysis should be performed in patients with transferrin ≥45% and/or elevated serum ferritin. (Strong recommendation, very low level of evidence).
- Patients with abnormal AST and ALT levels, especially those with other autoimmune conditions, should be tested for autoimmune liver disease including ANA, ASMA, and globulin levels. (Strong recommendation, very low level of evidence).
- Patients with persistently elevated AST and ALT levels, especially those under 55 years of age, should be screened for Wilson’s disease with a serum ceruloplasmin test. If low ceruloplasmin is found, confirmatory testing with a 24-hour urine copper test and slit-lamp eye examination for abnormalities (Kaiser-Fleischer mosaic rings) is recommended. (Strong recommendation, very low level of evidence).
- Patients with persistently elevated AST or ALT should be screened for alpha-1 antitrypsin deficiency (A1AT) with the alpha-1 antitrypsin phenotype. (Strong recommendation, very low level of evidence).
- Doctors should ask patients with abnormal kidney tests about their medications and medications, including those they take on their own, without a doctor’s recommendation. It is also worth considering dietary or herbal supplements that may be associated with DILI. (Strong recommendation, very low level of evidence).
- Liver biopsy may be considered when serological testing and imaging fail to reveal a diagnosis, interpret the condition, or when multiple diagnoses are possible. (Strong recommendation, very low level of evidence).
- An increase in alkaline phosphatase should be confirmed by an increase in GGT. Given the lack of specificity for liver disease, GGT should not be used as a screening test for underlying liver disease in the absence of other abnormal liver findings. (Strong recommendation, very low level of evidence).
- Patients with alkaline phosphatase elevation with or without bilirubin elevation should be tested for PBC (formerly called primary biliary cirrhosis) with antimitochondrial antibody testing. (Strong recommendation, very low level of evidence).
- Patients with alkaline phosphatase elevation with or without bilirubin elevation should be tested for PSC by MR cholangiography or ERCP with IgG4. (Strong recommendation, very low level of evidence).
- In patients with ALT and/or AST levels <5X ULN, laboratory investigations should evaluate the possibility of viral hepatitis B and C, alcoholic and NAFLD, hemochromatosis, Wilson's disease, alpha-1 antitrypsin deficiency, autoimmune hepatitis and consider the possibility of drug poisoning and associated with them liver damage. (Strong recommendation, very low level of evidence).
- In individuals with an ALT and/or AST level of 5-15X ULN, acute hepatitis A, B, and C should be considered in addition to all etiologies. (Strong recommendation, very low level of evidence).
- In individuals with ALT and/or AST > 15X ULN or massive ALT elevation > 10,000 IU/L, acetaminophen toxicity and ischemic hepatopathy (liver shock) should be considered. (Strong recommendation, very low level of evidence).
- A patient with acute hepatitis with elevated prothrombin time and/or encephalopathy requires immediate referral to a hepaologist. liver specialist. (Strong recommendation, very low level of evidence).
Risk factors for hepatitis C include a history of intranasal or intravenous drug use, tattoos, piercings, blood transfusions, and high-risk sexual behavior. Also at risk are people born between 1945 and 1965. Testing for acute hepatitis C is done with anti-HCV and HCV RNA by nucleic acid testing. (Strong recommendation, very low level of evidence).
(Strong recommendation, very low level of evidence).
It is also worth considering dietary or herbal supplements that may be associated with DILI. (Strong recommendation, very low level of evidence).
(Strong recommendation, very low level of evidence).
liver specialist. (Strong recommendation, very low level of evidence).ALT, alanine aminotransferase; ANA, antinuclear antibodies; ASMA, anti-smooth antibody; AST, aspartate aminotransferase; BMI, body mass index; DILI, drug-induced liver injury; GGT, gamma-glutamyl transferase; HAV, hepatitis A virus; HBc, hepatitis B major antigen; HBsAg, hepatitis B surface antigen; HCV, hepatitis C virus; HEV, hepatitis E virus; HFE, hereditary hemochromatosis; IgM, immunoglobulin M; MR, magnetic resonance; NAFLD, non-alcoholic fatty liver disease; PBC, primary biliary cholangitis; PSC, primary sclerosing cholangitis; ULN, upper limit of normal
Contributors to the guidelines:
Division of Gastroenterology/Hepatology, Department of Medicine, Stanford University School of Medicine Palo Alto, California, USA; Digestive Health Institute, University Hospitals Cleveland Medical Center and Division of Gastroenterology and Liver Disease, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA; Yale Viral Hepatitis Program, Yale University School of Medicine.