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What blood test for liver. Comprehensive Guide to Liver Panel Tests: Diagnosis, Monitoring, and Interpretation

by alexxlab

What is a liver panel test. How is a liver panel test conducted. Why are liver panel tests important for health assessment. What components are included in a standard liver panel. When should you consider getting a liver panel test. How are liver panel test results interpreted. Can liver panel tests detect all liver diseases.

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Understanding the Liver Panel Test: A Vital Diagnostic Tool

A liver panel test, also known as a liver function test, is a crucial diagnostic tool used to assess the health and functionality of the liver. This comprehensive blood test measures various components that provide insights into liver health, potential diseases, and overall bodily functions influenced by this vital organ.

What exactly is a liver panel test?

A liver panel test is a multi-component blood analysis that evaluates different aspects of liver function and health. It typically involves drawing a blood sample from a vein in your arm, which is then analyzed in a laboratory for specific markers related to liver health.

Why are liver panel tests important?

Liver panel tests play a crucial role in:

  • Diagnosing liver diseases and disorders
  • Monitoring existing liver conditions
  • Screening for potential liver issues
  • Assessing the impact of medications on liver function
  • Evaluating overall health as part of routine check-ups

Key Components of a Standard Liver Panel Test

While the exact components of a liver panel test may vary depending on the healthcare provider’s discretion, most standard panels include the following measurements:

Aspartate Aminotransferase (AST)

AST is an enzyme found in various tissues, including the liver, heart, and muscles. Elevated levels of AST in the blood can indicate liver damage or disease, although it’s not specific to liver issues alone.

Alanine Aminotransferase (ALT)

ALT is an enzyme primarily found in the liver. Increased ALT levels are often a more specific indicator of liver damage or disease compared to AST.

Alkaline Phosphatase (ALP)

ALP is an enzyme present in the liver, bones, and other tissues. Elevated ALP levels can suggest liver or bone disorders, among other conditions.

Bilirubin

Bilirubin is a yellow pigment produced during the breakdown of red blood cells. The liver is responsible for processing and eliminating bilirubin from the body. High bilirubin levels can indicate liver dysfunction or other health issues.

Albumin

Albumin is the most abundant protein in the blood and is produced by the liver. Low albumin levels may suggest liver disease or other health problems affecting protein production or retention in the body.

Additional Components in Comprehensive Liver Panels

Depending on the specific diagnostic needs, healthcare providers may include additional measurements in a liver panel test:

  • Gamma-glutamyl transferase (GGT)
  • 5′ nucleotidase (5′-NT)
  • Total protein
  • Globulins
  • Prothrombin time
  • Lactate dehydrogenase (LDH)

These additional components can provide more detailed information about liver function and help identify specific liver conditions or other health issues affecting the liver.

When Should You Consider Getting a Liver Panel Test?

There are several scenarios in which a liver panel test may be recommended or necessary:

Routine Health Check-ups

Liver panel tests are often included as part of comprehensive metabolic panels during regular medical check-ups. This proactive approach helps detect potential liver issues before they become more serious.

Presence of Liver Disease Symptoms

If you experience symptoms that could indicate liver problems, your healthcare provider may order a liver panel test. These symptoms may include:

  • Jaundice (yellowing of the skin and eyes)
  • Nausea and vomiting
  • Abdominal pain or swelling
  • Dark urine
  • Pale stools
  • Chronic fatigue
  • Loss of appetite
  • Unexplained weight loss

Monitoring Existing Liver Conditions

For individuals with known liver diseases such as hepatitis, cirrhosis, or fatty liver disease, regular liver panel tests help track the progression of the condition and assess the effectiveness of treatments.

Medication Side Effect Monitoring

Some medications can potentially affect liver function. If you’re taking such medications, your healthcare provider may recommend periodic liver panel tests to ensure your liver remains healthy.

Risk Factors for Liver Disease

Individuals with risk factors for liver disease may benefit from regular liver panel testing. These risk factors include:

  • Heavy alcohol consumption
  • Obesity
  • Diabetes
  • Family history of liver disease
  • Exposure to certain toxins or chemicals

Interpreting Liver Panel Test Results

Interpreting liver panel test results requires medical expertise, as the significance of the results can vary based on individual factors and overall health context.

Normal Range vs. Abnormal Results

Each component of the liver panel has a specific range considered normal. Results falling outside these ranges may indicate potential liver issues or other health problems. However, it’s important to note that slight deviations from the normal range don’t always signify a serious problem.

What do elevated liver enzymes indicate?

Elevated liver enzymes, such as AST and ALT, can suggest liver cell damage or inflammation. However, the specific pattern and degree of elevation can provide clues about the underlying cause. For example:

  • Mild elevations may be due to temporary factors like certain medications or recent alcohol consumption
  • Moderate elevations could indicate chronic liver diseases like hepatitis or fatty liver disease
  • Severe elevations might suggest acute liver injury or advanced liver disease

Bilirubin levels and their significance

Elevated bilirubin levels can cause jaundice and may indicate various liver or blood disorders. The type of bilirubin elevation (direct or indirect) can help pinpoint the underlying issue:

  • Elevated indirect bilirubin may suggest hemolytic anemia or Gilbert’s syndrome
  • Elevated direct bilirubin often indicates liver disease or bile duct obstruction

Albumin and protein levels

Low albumin levels can indicate chronic liver disease, malnutrition, or other conditions affecting protein production or retention. Total protein levels, when considered alongside albumin, can provide additional insights into liver function and overall health.

Limitations of Liver Panel Tests

While liver panel tests are valuable diagnostic tools, they do have some limitations:

Can liver panel tests detect all liver diseases?

No, liver panel tests cannot detect all liver diseases. Some conditions, particularly in their early stages, may not cause significant changes in the measured components. Additionally, certain liver diseases may require more specific tests for accurate diagnosis.

False positives and negatives

Like all medical tests, liver panel tests can sometimes produce false positive or false negative results. Factors such as medications, recent alcohol consumption, or other health conditions can affect test results, potentially leading to misinterpretation if not considered in the broader clinical context.

Need for additional testing

In many cases, abnormal liver panel results will necessitate further testing to determine the underlying cause. This may include imaging studies (such as ultrasound or CT scans), more specific blood tests, or even liver biopsies in some cases.

Preparing for a Liver Panel Test

Proper preparation can help ensure accurate liver panel test results:

Fasting requirements

In most cases, you’ll need to fast for 8-12 hours before the test. This means avoiding all food and drinks except water. Your healthcare provider will provide specific instructions based on your individual circumstances.

Medication considerations

Inform your healthcare provider about all medications, supplements, and herbal products you’re taking. Some of these may affect liver panel results, and your provider may advise you to temporarily stop taking certain substances before the test.

Lifestyle factors

Avoid alcohol consumption for at least 24 hours before the test, as alcohol can temporarily elevate liver enzyme levels. Also, inform your healthcare provider about any recent changes in diet or exercise habits, as these can sometimes influence test results.

Beyond the Liver Panel: Comprehensive Liver Health Assessment

While liver panel tests provide valuable information about liver health, a comprehensive assessment often involves additional measures:

Imaging studies

Ultrasound, CT scans, or MRI can provide detailed images of the liver, helping detect structural abnormalities, tumors, or signs of cirrhosis that may not be evident from blood tests alone.

Specialized blood tests

Depending on the suspected liver condition, additional blood tests may be ordered. These might include tests for specific types of hepatitis, autoimmune liver diseases, or genetic liver disorders.

Liver biopsy

In some cases, a liver biopsy may be necessary to definitively diagnose certain liver conditions or assess the severity of liver damage. This involves removing a small sample of liver tissue for microscopic examination.

Lifestyle and risk factor assessment

A thorough evaluation of lifestyle factors, including alcohol consumption, diet, and exercise habits, as well as assessment of risk factors like obesity or diabetes, is crucial for a comprehensive understanding of liver health.

By combining liver panel test results with these additional assessments, healthcare providers can gain a more complete picture of liver health and function, enabling more accurate diagnoses and tailored treatment plans.

Maintaining Liver Health: Preventive Measures and Lifestyle Choices

While regular liver panel tests are important for monitoring liver health, there are several preventive measures and lifestyle choices that can help maintain a healthy liver:

Alcohol moderation

Limiting alcohol consumption is one of the most effective ways to protect your liver. If you choose to drink, do so in moderation. For most adults, this means up to one drink per day for women and up to two drinks per day for men.

Balanced diet and weight management

Maintaining a healthy weight through a balanced diet can help prevent non-alcoholic fatty liver disease (NAFLD). Focus on a diet rich in fruits, vegetables, whole grains, and lean proteins, while limiting processed foods and saturated fats.

Regular exercise

Physical activity not only helps maintain a healthy weight but also improves overall liver function. Aim for at least 150 minutes of moderate-intensity exercise or 75 minutes of vigorous-intensity exercise per week.

Hepatitis prevention

Protect yourself against viral hepatitis by practicing safe sex, avoiding sharing needles, and getting vaccinated against hepatitis A and B. There’s currently no vaccine for hepatitis C, but screening and early treatment can prevent long-term liver damage.

Medication awareness

Be cautious with medications, including over-the-counter drugs and supplements. Some medications can be harmful to the liver when taken in large doses or for extended periods. Always follow prescribed dosages and consult with your healthcare provider about potential liver effects.

Limiting toxin exposure

Minimize exposure to environmental toxins that can harm the liver. This includes being cautious with cleaning products, pesticides, and other chemicals. If you work with potentially harmful substances, follow safety guidelines and use protective equipment.

Regular check-ups

Schedule regular check-ups with your healthcare provider, including liver panel tests when recommended. Early detection of liver issues can lead to more effective treatment and better outcomes.

By incorporating these preventive measures and making informed lifestyle choices, you can significantly reduce your risk of liver disease and maintain optimal liver health. Remember, the liver has a remarkable ability to regenerate and heal itself when given the right conditions and care.

Liver Panel Test – Testing.com

Test Quick Guide

A liver panel is a test with multiple measurements that help assess the health and function of the liver. The test is conducted with a blood sample that is normally taken from a vein in your arm.

A liver panel can be used to help diagnose and monitor liver diseases. It can also provide information about other health conditions that affect the liver, such as viral or alcoholic hepatitis. If you are taking medications that can impact the liver, the test results can determine whether side effects are occurring.

About the Test

Purpose of the test

The liver panel has many applications in medical care. While sometimes called a liver function test, it is better understood as a method of detecting liver disease and/or other health problems, including many that involve the liver.

Some of the specific ways that a liver panel can be used include:

  • Diagnosis: Although a liver panel alone is not able to diagnose liver diseases, its measurements can help identify the type of problem if you have symptoms of liver conditions. The test can also help in the diagnostic process of other health concerns.
  • Evaluating disease severity: A liver panel can help determine the extent of illness if you have known liver problems.
  • Screening: You may have a liver panel as part of broader blood testing, known as the comprehensive metabolic panel, during routine medical checkups. If screening is abnormal, it may warrant more specific follow-up testing.
  • Monitoring: Follow-up testing can provide information about how well treatment for liver problems is working. A liver panel can also monitor for side effects when you take medications that can impact liver health.

What does the test measure?

As a panel test, the liver panel involves multiple measurements. When the test is ordered, doctors can modify exactly which measurements to take.

For this reason, there is not a universal standard for what is measured on a liver panel. Nevertheless, some components of the test are more common. In most cases, a liver panel includes the following measurements:

  • Aspartate aminotransferase (AST): This is a type of protein called an enzyme that is found in the liver as well as many muscles and organs.
  • Alanine aminotransferase (ALT): This is an enzyme found primarily in the liver.
  • Alkaline phosphatase (ALP): This is an enzyme found in the liver, bones, and other tissues in the body.
  • Bilirubin: Bilirubin is a yellow-colored waste product that is the result of the normal breakdown of red blood cells. The liver works to remove bilirubin from the body.
  • Albumin: Albumin is the most abundant protein in the blood and is made by the liver which prevents fluids from leaking out of the bloodstream.

Additional measurements may be added to a liver panel if the doctor believes they can provide more information to evaluate your situation. These measures may be tested on an initial liver panel, or included in repeat testing after an abnormal result on a previous test.

  • Gamma-glutamyl transferase (GGT): An enzyme found in the liver and other organs.
  • 5’ nucleotidase (5’-NT): An enzyme that exists in the liver and other organs.
  • Total protein: Measures the sum of all proteins in the blood.
  • Globulins: A class of proteins in the blood.
  • Prothrombin time: A protein made by the liver that facilitates normal blood clotting and measures how long it takes for the blood to clot.
  • Lactate dehydrogenase (LDH): An enzyme found in tissues throughout the body.

When should I get a liver panel?

There are many reasons you might decide to get a liver diagnostic test, or why a health care professional will order the lab test for you. This test can detect liver disease and other health problems involving the liver. You might be taking medications with liver damage as a side effect, and the test can measure whether the prescription is having a negative impact on your health. A liver panel can also be done as part of a metabolic panel during a routine medical visit.

A doctor might recommend a liver panel if you show common symptoms like jaundice (yellowing of the skin and eyes), nausea and vomiting, diarrhea, dark-colored urine, light-colored stool, or fatigue. The tricky thing is, aside from jaundice, these symptoms can easily be written off as “something else.”

That’s why it’s really important to consult with your doctor, who can advise whether a liver panel is necessary as part of an overall medical checkup or because of specific circumstances, such as monitoring cirrhosis or medication side effects.

Finding a Liver Panel

How can I get a liver panel?

Liver panel testing is performed in a medical setting such as a clinic, hospital, doctor’s office, or lab. Your doctor may order the liver panel, or you can purchase the test online and be referred to a nearby participating lab for the sample. Most liver panel testing happens with a blood draw and laboratory analysis. But there is a type of rapid, on-site point-of-care test that can measure certain components of the liver panel. It is not comprehensive.

Can I take the test at home?

There are at-home liver panel tests that can determine liver function by screening for proteins and enzymes like albumin, globulin, ALP, ALT, and GGT. These tests use a finger-prick sample and include materials to collect and send your specimen to the lab.

You can order a liver panel from home and get tested in a lab. Or, your doctor can prescribe the liver panel.

The at-home liver panel test is focused on liver function but does not provide the comprehensive results that an expanded liver panel does. It also tests for direct bilirubin and total bilirubin (waste produced by the liver), and AST, an enzyme found in the liver and other tissues.

How much does the test cost?

If you get a liver test ordered by a doctor, your insurance policy may cover the cost of the appointment and lab analysis. There may be a copay or deductible, however. If you order the test online, you can submit the receipt for potential reimbursement. You can find affordable liver panel testing that ranges in price from $39 to $79.

Before you order your own test from a lab or arrange a doctor-ordered liver panel, ask about costs, insurances accepted, copays, and deductibles. Be sure to refer to your doctor, lab, and health plan for details on test costs and insurance coverage.

Taking a Liver Panel Test

A liver panel requires drawing blood from a vein in your arm. The procedure is routine and performed in a medical office, clinic, hospital, or lab. There are some at-home tests available that involve a skin prick, but they are not as thorough as a liver panel from a lab.

Before the test

Plan on fasting for up to 12 hours before you take a liver panel test, only drinking water during this time. Also, be sure your doctor knows what medications you are taking because some prescription drugs and over-the-counter medications or dietary supplements can interfere with the test. Your doctor will provide specific guidelines on which medications and for how long to avoid them before a liver panel blood draw.

Not all liver panels require preparation. For example, an expanded liver panel you order online and go to a lab for testing does not require fasting. The comprehensive liver panel you can order online for lab testing does require fasting for 12 to 14 hours.

For at-home finger-prick liver tests, be sure to read the instructions carefully so you know whether the preparation is required.

During the test

A routine blood draw is all that is required to perform a liver panel. With a small needle, blood is drawn from a vein in your arm into a vial and analyzed by a lab. The phlebotomist will carefully clean the area first with antiseptic, and you might feel a sting when the needle is inserted or removed. You could experience mild bruising or soreness after the test like if you were getting blood drawn for any other medical panel. The entire process takes no more than five minutes.

At-home tests require a finger prick. The kit will include a lancet or small needle. You’ll get a test strip where you apply the blood drops, and then secure it in the provided packaging to send to the lab. It takes less than a minute to gather your sample and prepare the dry blood card for the lab. Remember, test kit instructions vary, so it’s important to read all instructions before obtaining your blood sample.

After the test

There are no restrictions after getting blood drawn for a liver panel, but if you fasted for 12 to 14 hours prior to the lab test, you will probably feel weak or fatigued. Consider bringing a snack for after your test. You can return to standard activities. Other than changing an adhesive bandage, there’s little to no recovery.

Liver Panel Test Results

Receiving test results

Depending on what type of liver panel you get, you can expect test results within one to two business days for an expanded panel that measures enzymes and proteins. It many take one to two days for a comprehensive panel that assesses enzymes and proteins to determine liver function, including GGT and LD. The comprehensive panel is also called hepatic function testing.

Lab result times can vary, so ask the clinician in advance how long it will take. Even at-home tests that use a finger prick to collect a blood sample will take a few business days from the time the lab receives your sample before you get results.

The speed of results can also depend on how you get them. Labs deliver results in a number of ways, including confidential phone calls, secure emails, or via an app.

Interpreting test results

Your liver panel test results will depend on the type of test. You will see some reference ranges to understand what levels are considered abnormal. Always discuss these results with a medical professional so you can ask questions and gain a clear understanding of the report, its information, and the next steps.

There are five common measures your liver panel test results will reveal.

  • Bilirubin: Total bilirubin will show whether levels are raised due to a metabolic disorder or liver disease. In infants, it can indicate whether support is needed to address a liver that is not functioning properly.
  • Albumin: This protein can be a marker for liver function and reduced albumin could indicate sepsis, inflammatory disorders, and other liver problems.
  • ALP: Higher levels of ALP can be found in those with liver and bone disease.
  • AST and ALT: These are liver enzymes and elevation can indicate liver-related issues. ALT can be an indicator of liver cell injury.
  • GGT: This is used in the diagnosis and treatment of liver disease and in the evaluation of patients with alcoholism.

When test results are abnormal, doctors often look for certain patterns of abnormalities in the specific levels that were detected.

  • Conditions involving acute or chronic liver damage often show disproportionate increases in ALT and AST compared to ALP.
  • Bile duct obstruction is more often associated with a disproportionate increase in ALP compared to ALT and AST.
  • Disorders affecting the normal processing of bilirubin may be demonstrated by elevated bilirubin with normal levels of ALT, AST, and ALP.
  • Health conditions originating outside the liver are more common when abnormal albumin or prothrombin time occurs with otherwise normal results.

Your doctor will look at these test results and take into account your health, symptoms, and medical and family history. Any drugs you take are also considered since some medications can impact test results. Liver panel results are complex, so always review results with a medical professional who understands your case and can answer your questions. Here are some to ask:

  • Was any part of my test result abnormal?
  • If there was an abnormal result, can you explain what was found and what it may mean?
  • If results were normal, will I need to have this testing again at any point in the future?
  • Are there any follow-up tests that may be beneficial given my test results?
  • CMP Blood Test (Comprehensive Metabolic Panel)
    Learn More
  • Alanine Aminotransferase (ALT)
    Learn More
  • Alkaline Phosphatase (ALP) Test
    Learn More
  • Albumin Blood Test
    Learn More
  • Total Protein, Albumin-Globulin (A/G) Ratio Test
    Learn More
  • Bilirubin Test
    Learn More
  • GGT Blood Test (Gamma Glutamyl Tranferase/Transpeptidase)
    Learn More
  • Lactate Dehydrogenase (LDH) Test
    Learn More
  • PT/INR Test (Prothrombin Time and International Normalized Ratio)
    Learn More

Resources

  • National Library of Medicine: Liver Diseases
  • National Institute of Diabetes and Digestive and Kidney Diseases: Liver Disease
  • American Liver Foundation: Diagnosing Liver Disease

Sources

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Blood tests for liver cancer

Blood tests can:

  • check your general health, including how well your liver and kidneys are working 
  • check numbers of blood cells 

You might also have a blood test to look at the level of a chemical called alpha fetoprotein (AFP). This might be higher than normal in some types of liver cancer. This might help to diagnose a possible cancer or other conditions. You have blood tests in combination with other tests.

Preparing for your blood tests

You can eat and drink normally before most blood tests. For fasting blood tests you need to stop eating and drinking beforehand. Your doctor will tell you for how long.

What happens?

You sit or lie down to have the test.

A doctor, nurse or phlebotomist (person specialised in taking blood) chooses the best vein to use. This is usually from your arm or hand. Let them know if you are afraid of needles, get unwell with the sight of blood or are allergic to plasters or latex.  

They put a tight band (tourniquet) around your arm above the area where they take the sample. You may need to clench your fist to make it easier to find a vein.

They clean your skin and then put a small needle into your vein. Next, they attach a small bottle or syringe to the needle to draw out some blood. They might fill several small bottles.

Once they have all the samples, they release the band around your arm. They then take the needle out and put pressure on the area with a cotton wool ball or small piece of gauze for a few minutes. This helps to stop bleeding and bruising.

Look away when they’re taking the blood if you prefer. Tell your doctor, nurse or phlebotomist if you feel unwell.

Getting your results

Ask the phlebotomist, doctor or nurse when and how you will get your results. Some results might be available very quickly, such as a full blood count and kidney and liver function tests. Other tests might take several weeks.

Possible risks of having a blood test

Blood sampling (phlebotomy) is a safe test. There is a possibility of:

  • bleeding and bruising – pressing hard when the needle is removed can help to stop it
  • pain – this is normally mild and can last for a few minutes
  • swelling (oedema) – ask your nurse, doctor or phlebotomist to avoid an arm that is swollen or has a risk of swelling
  • feeling faint or fainting – tell the person doing your blood test if you’re feeling lightheaded or dizzy at any time
  • infection – this is very rare

Types of blood tests

Liver function tests (LFTs)

Liver function tests (LFTs) check how well your liver is working. LFTs look for levels of enzymes and proteins made by the liver or which are cleared by the liver. They include:

  • alanine aminotransferase (ALT)
  • aspartate aminotransferase (AST)
  • alkaline phosphatase (ALP)
  • gamma-glutamyl transferase (Gamma GT)

They might be raised if you have a blockage in your liver or bile duct, or if you drink a lot of alcohol.

LFTs also look at the amount of bilirubin in the blood. This is a chemical in bile. Bilirubin can be raised if you have a problem with your liver or gallbladder. Bilirubin can cause yellowing of your skin and eyes (jaundice). 

LFTs also measure albumin. This is a protein in the blood that can be low when you have some types of cancer. You can also have low albumin if you’ve been eating small amounts and are malnourished.

Full blood count

A full blood count (FBC) measures the number of red cells, white cells and platelets in your blood.

  • Red cells carry oxygen around our bodies. Haemoglobin is the part of the cell that carries oxygen. If you have a low red cell count, your doctor might say you’re anaemic (pronounced a-nee-mic). This can make you feel tired, short of breath and dizzy.
  • White cells fight infections. There are several different types of white cells, including neutrophils and lymphocytes.
  • Platelets help clot the blood, for example after a cut. Symptoms of a low platelet count include abnormal bleeding, such as bleeding gums and nosebleeds.

There is a range of normal for blood counts. The range of figures quoted as normal varies slightly between laboratories and also differs between men and women. 

Urea and electrolytes

These blood tests show how well your kidneys are working. Waste chemicals called urea and creatinine are produced by the body. Our kidneys remove them from our blood and get rid of them in our urine.

Electrolytes are substances such as sodium, potassium, chloride and bicarbonate.

Tumour markers

Tumour markers are substances that might be raised if there is a cancer. They’re usually proteins. They can be found in the blood, urine or body tissues. 

Some tumour markers are only produced by one type of cancer. Others can be made by several types. Some markers are found in non cancerous conditions as well as cancer.

Doctors might use tumour markers to monitor how well your cancer treatment is working or check if the cancer has come back. 

In some people with hepatocellular cancer (HCC) and hepatoblastomas the level of a chemical called alpha fetoprotein (AFP) is higher than normal. It can be a marker for HCC but the level can also sometimes be raised in people with liver cirrhosis who do not have HCC.

It is useful for doctors to measure the level of AFP before and after treatment for primary liver cancer as this may give them an idea about how successful treatment has been.

  • Oxford handbook of clinical medicine (10th edition)
    T Raine, K Wiles and others
    Oxford University Press, 2019

  • EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma
    European Association for the Study of the Liver
    Journal of Hepatology, 2018. Volume 69, Pages 182-236

  • Suspected cancer: recognition and referral
    National Institute of Health and Care Excellence, June 2015 (updated 2021)

  • Hepatocellular carcinoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow up
    A Vogel and others
    Annals of Oncology, 2018. Volume 29, Supplement 4, Pages 238-255

Last reviewed: 

27 Sep 2021

Next review due: 

27 Sep 2024