Evaluation of Abnormal Liver Function Tests

Dr Chris Hovell Consultant Gastroenterologist Dorset County Hospital

LFTs

Markers of hepatocellular damage

Cholestasis Liver synthetic function

Markers of Hepatocellular damage (Transaminases)

AST- liver, heart skeletal muscle, kidneys, brain, RBCs

In liver 20% activity is cytosolic and 80% mitochondrial Clearance performed by sinusoidal cells, half-life 17hrs

ALT more specific to liver, v.low concentrations in

kidney and skeletal muscles. In liver totally cytosolic. Half-life 47hrs

Gamma-GT hepatocytes and biliary epithelial cells,

pancreas, renal tubules and intestine Very sensitive but Non-specific Raised in ANY liver discease hepatocellular or cholestatic Usefulness limited Confirm hepatic source for a raised ALP Alcohol Isolated increase does not require any further evaluation, suggest watch and rpt 3/12 only if other LFTs become abnormal then investigate

Markers of Cholestasis

ALP liver and bone (placenta, kidneys, intestines or

WCC) Hepatic ALP present on surface of bile duct epithelia and accumulating bile salts increase its release from cell surface. Takes time for induction of enzyme levels so may not be first enzyme to rise and half-life is 1 week. ALP isoenzymes, 5-NT or gamma GT may be necessary to evaluate the origin of ALP

Bilirubin, Albumin and Prothrombin time (INR)

Useful indicators of liver synthetic function In primary care when associated with liver disease abnormalities should raise concern Thrombocytopaenia is a sensitive indicator of liver fibrosis

Patterns of liver enzyme alteration

Hepatic vs cholestatic
Magnitude of enzyme alteration (ALT >10x vs minor abnormalities) Rate of change Nature of the course of the abnormality (mild fluctuation vs progressive increase)

Patterns of liver enzyme alteration

Acute hepatitis transaminase > 10x ULN

Cholestatic Mild rise in ALT

Acute hepatitis (ALT>10xULN)

Viral Ischaemic Toxins Autoimmune Early phase of acute obstruction

Acute hepatitis (ALT>10xULN)

Viral Hep A, B, C, E, CMV, EBV ALT levels usually peak before jaundice appears. Jaundice occurs in 70% Hep A, 35% acute Hep B, 25% Hep C Check for exposure Check Hep A IgM, Hep B core IgM and HepBsAg, Hep C IgG or Hep C RNA

Acute hepatitis (ALT>10xULN)

Ischaemic- sepsis, hypotension ?most common cause in-patients Often extremely high >50x Decrease rapidly LDH raised 80% Rarely jaundiced

Acute hepatitis (ALT>10xULN)

Toxins - paracetamol (up to 50% of all cases of Acute Liver Failure) Ecstasy ( 2nd most common cause in the young <35) Any drug herbal remedies Alcohol almost never, AST <7xULN in 98% AST/ALT ratio > 1 in 92%, >2 in 70%

Acute hepatitis (ALT>10xULN)

Autoimmune Rarely presents with acute hepatitis Usually jaundiced and progressive liver failure Raised IgG and autoantibodies (anti-SM, -LKM, SLA) Liver biopsy Steroids and azathioprine

Acute hepatitis (ALT>10xULN)

Early phase- extrahepatic obstruction/cholangitis Usually have history of pain USS dilated CBD ? ERCP or lap chole

Cholestasis

Isolated ALP 3rd trimester, adolescents Bone exclude by raised GGT, 5-NT or isoenzymes May suggest biliary obstruction, chronic liver disease or hepatic mass/tumour Liver USS/CT most important investigationdilated ducts Ca pancreas, CBD stones, cholangioca or liver mets

Cholestasis non-dilated ducts

Cholestatic jaundice Drugs- Antibiotics, Nsaids, Hormones, ACEI PBC anti- mitochondrial Ab, M2 fraction, IgM PSC associated with IBD 70%, p-ANCA, MRCP and liver biopsy Chronic liver disease Cholangiocarcinoma beware fluctuating levels Primary or Metastatic cancer, lymphoma Infiltrative sarcoid, inflammatory-PMR, IBD Liver biopsy often required

Dear Dr Hepaticus, I have just reviewed our patient data base and have identified 420 patients with persistently abnormal LFTs who are otherwise well and are not known to have liver disease. When can you see them? Yours, Dr G Practice

COMMON CAUSES OF ABNORMAL LFTS IN THE UK

Transient mild abnormalities which are simply impossible to explain Drugs eg Statins Alcohol excess Hepatitis C Non-Alcoholic Fatty Liver Disease (NAFLD)

Investigation of Abnormal LFTs

PRINCIPLES 2.5% of population have raised LFTs Normal LFTs do not exclude liver disease Interpret LFTs in clinical context Take a careful history for risk factors, drugs (inc OTCs), alcohol, comorbidity, autoimmunity Physical examination for liver disease Chase likely diagnosis rather than follow algorithm unless there are no clues If mild abnormalities and no risk factors or suggestion of serious liver disease , repeat LFTs after an interval (with lifestyle modification)

Investigation of Abnormal LFTs ALT/AST 2-5x normal (100-200)

History and Examination Discontinue hepatotoxic drugs Continue statins but monitor LFTs monthly Lifestyle modification (lose wt, reduce alcohol, diabetic control) Repeat LFTs at 1 month and 6 months

Investigation of Abnormal LFTs - Raised ALT / AST

If still abnormal at 6 months: Consider referral to secondary care Hepatitis serology (B, C) Iron studies transferrin saturation + ferritin Autoantibodies & immunoglobulins Consider caeruloplasmin Alpha-1- antitrypsin Coeliac serology TFTs, lipids/glucose Consider liver biopsy esp if ALT > 100)

Hepatits C
Most asymptomatic; acute hepatitis with jaundice is uncommon 80% will have chronic / persistent infection. Of these, 10% will develop cirrhosis of the liver 10 years after infection 20-30% will develop cirrhosis of the liver 30 years after infection 5% will develop hepatocellular carcinoma (liver cancer) 20 years after infection.

Hepatitis C: Factors associated with progression of liver disease

The genotype of the virus -IB
Acquiring the infection at an older age Alcohol misuse Male gender Co-infection with Hepatitis B or HIV

Treatment of Hepatitis C
Hep C RNA by PCR Liver biopsy for genotype I, treatment is recommended for patients with moderate to severe hepatitis Peg-interferon given by sc injection 1/ week, Ribavirin bd dose Patients with genotypes II and III are treated with for 6 months. Response rate 70% Patients with genotypes I, IV, V, and VI are treated with interferon and ribavirin for 12 months, if responsive on viral load at 3/12. Response rate 30%-40%.

Prevalence of Inherited Liver Diseases

Disease
Homozygote Frequency Gene Frequency Heterozygote Frequency

Haemochromatosis 1:400 1AT Deficiency Cystic Fibrosis Wilson's Disease

1:20 1:40 1:50 1:170

1:10 1:20 1:25 1:85

1:1600 1:2500 1:30,000

Leggett et al Brit J. Haem. 1990

Genetics of Haemochromatosis

Autosomal recessive Mutations in HFE gene (C282Y and H63D) Cause increased intestinal absorption of Fe
C282Y/C282Y and C282Y/H63D are responsible for 95% of genetic haemochromatosis

Clinical Manifestations of haemochromatosis

Skin pigmentation Liver disease Diabetes mellitus Arthropathy Impotence Fatigue Cardiomegaly

Screening Strategy for Haemochromatosis (HFE Associated)

1. Perform transferrin saturation (or UIBC) 2. If 45% - repeat fasting 3. If still 45% - perform HFE testing 4. If C282Y +/+ or C282Y/H63D +/+: - perform serum ferritin and LFT - if SF > 1000 and/or LFT abnormal - Liver biopsy essential 5. If C282Y +/- : - Counsel re: Alcohol NASH HCV PCT 6. Venesection and family screening

Liver biopsy Findings in Abnormal LFTs

Skelly et al: 354 Asymptomatic patients Transaminases persistently 2X normal No risk factors for liver disease Alcohol intake < 21 units/week Viral and autoimmune markers negative Iron studies normal
Skelly et al. J Hepatol 2001; 35: 195-294

Liver biopsy Findings in Abnormal LFTs Skelly et al. J Hepatol 2001

6% Normal 26% Fibrosis 6% Cirrhosis 34% NASH (11% of which had bridging fibrosis and 8% cirrhosis) 32% Simple Fatty Liver 18% Alteration in Management 3 Families entered into screening programmes

Other Liver biopsy Findings in Abnormal LFTs Skelly et al. J Hepatol 2001

Cryptogenic hepatitis Drug induced Alcoholic liver disease Autoimmune hepatitis PBC PSC Granulomatous disease Haemochromatosis Amyloid Glycogen storage disease

9% 7.6% 2.8% 1.9% 1.4% 1.1% 1.75% 1% 0.3% 0.31%

What is the Value of Liver Biopsy in Abnormal LFTs?

The most accurate way to grade the severity of liver disease Aminotransferase levels correlate poorly with histological activity Narrows the diagnostic options, if not diagnostic

LIVER BIOPSY FOR SERONEGATIVE ALT < 2X NORMAL

N = 249, mean age 58, etoh < 25 units per week, 9% diabetes, 24% BMI > 27 ALT 51-99 (over 6 m)
72% NAFLD 10% Normal histologically
Others: Granulomatous liver disease 4%, Autoimmune 2.7%, cryptogenic hepatitis 2.5%, ALD 1.4%, metobolic 2.1%, biliary 1.8%

Ryder et al BASL 2003

LIVER BIOPSY FOR SERONEGATIVE ALT < 2X NORMAL

Of those with NAFLD: 56% had simple steatosis 44% inflammation and/or fibrosis
Risk of Severe Fibrotic Disease associated with: BMI >27 Gamma GT > 2x normal
Ryder et al BASL 2003

Ultrasound in Liver Disease

Detects Fatty Liver Increased echogenicity may not be specific for fat Unable to detect Inflammation or cirrhosis (unless advanced)
Therefore unable to discriminate between

NASH and simple fatty liver or identify other types of liver disease (which may include fatty change)

Liver biopsy is the only way to make an accurate diagnosis It may be worth treating fatty liver for 6 months before considering referral for biopsy

Non-Alcoholic Fatty Liver Disease

The spectrum of Nonalcoholic Fatty Liver Disease

Type 1 Fat alone

Type 2
Type 3 Type 4 bodies

Fat + inflammation
Fat + ballooning degeneration Fat + fibrosis and/or Mallory

Only types 3 and 4 have been definitively shown to progress to advanced liver disease and can be classified as NASH

NAFLD - Classification and Causes

PRIMARY Increased insulin resistance syndrome Diabetes mellitus (type II) Obesity

Hyperlipidemia

NAFLD - Secondary Causes

Drugs
Corticosteroids Synth oestrogens Amiodarone Perhexiline Nifedipine Tamoxifen Tetracycline Chloroquine Salicylates

Surgical Procedures
Gastroplexy Jejunoileal bypass Extensive small bowel resection Biliopancreatic diversion

Miscellaneous
Hepatitis C Abetalipoproteinaemia Weber-Christian disease TPN with glucose Environmental toxins S.bowel diverticulosis Wilsons disease Malnutrition

IBD
HIV infection

Prevalence of NAFLD and NASH

No good data - histological diagnosis

Car Crash post mortem study - 24% NAFL, 2.4% NASH - Hilden et al 1977 (n=503) USS - 16.4- 23% NAFL (Italy, and Japan)

Prevalence of NAFLD / NASH High risk groups

Severely obese subjects - 25% incidence of NASH at laparoscopy Type 2 diabetes - 28-55% NAFL Hyperlipidaemia - 20-90% NAFL Approx 60% of NAFL occurs in females Many patients are neither obese nor diabetic
(Bacon et al 1994, George et al 1998)

Obesity and Fatty liver

Prevalence increases with weight Up to 80% of obese individuals Up to 10-15% of normal subjects
Correspondingly, 15-20% of morbidly obese subjects and 3% of non-obese subjects have NASH Increasing prevalence in children

AGA, Gastroenterology 2002

NAFLD - Clinical Features

Mostly an incidental finding in asymptomatic individuals ALT 2-5x normal AST:ALT < 1 except in severe injury ALP, GGT 2-3x normal <50% Bilirubin rarely raised RUQ discomfort, fatigue and malaise in some patients

NASH - Natural History

15-50% of NASH patients have fibrosis or cirrhosis at index biopsy James and Day 1998 In Aetiological studies NASH is now the most common cause of cryptogenic cirrhosis Caldwell
et al 1999, Poonwala et al 2000

In a 19 year follow up study, steatosis (alone) did not progess histologically Teli et al 1995

NASH - Natural History

10 year retrospective follow up study n = 98 11% Liver Related deaths in types 3 and 4 80% of those developing cirrhosis had fibrosis at index biopsy
.

30 25 20
%

28 21

15 10 5 0 1 2 NAFL Types 3 4 3.4 0

% Developing Cirrhosis
Matteoni et al 1999

NASH-natural history

Steatosis only can progress to cirrhosis 1-2 % over 5-17yrs (Danish and Italian studies) NASH + fibrosis cirrhosis 0% at 5yrs 12% at 8ys Prognosis in cirrhotics poor-30% developing liverrelated morbidity or mortality (liver failure + HCC) over short period

Adams et al Gastroenterology 2005

NASH - RISK FACTORS FOR FIBROSIS AND CIRRHOSIS

Independent risk factors in several studies:

Age >45 ALT > 2x normal AST/ALT ratio > 1 Obesity, particularly truncal Type 2 diabetes Insulin Resistance Hyperlipdaemia (trigycerides > 1.7) Hypertension Iron overload

NB: Studies are in selected groups; may not apply to all patien

NASH - Who Should Have a Liver biopsy?

To Identify Patients at Risk of Progression restrict biopsy to patients with some, if not all of:

ALT > 2x normal AST > ALT At least moderate central obesity NIDDM or Impaired glucose tolerance Hypertension Hypertriglyceridaemia
Day, Gut 2002;50:5585-588

PATHOGENESIS OF NASH Insulin Resistance is the First Hit

NASH should be viewed as part of a multifactorial disease Commonly associated with syndrome X 85% in a retrospective study (Wilner et al 2001) Treatment strategies may be directed at Insulin Resistance

NASH - TREATMENT

Steady Weight Loss - logical treatment Reduces fatty infiltration Improves LFTs CAUTION - In some patients, inflammation and fibrosis increase especially with rapid wt loss (cf gastric and intestinal bypass) Improved diabetic control - little histological

data Exercise - patients with NAFLD have very poor respiratory quotients. LFTs and RQ improve with exercise Elias 2001

NASH DRUG TREATMENT

No completed RCTs to date CLOFIBRAT

No improvement in LFTs or histology over 1

year in NASH (n=16)

Laurin et al 1996

Gemfobrozil
One randomized study, improved LFTs after 4

weeks (n=46) Basaranoglu et al 1999

NASH - Drug TREATMENT 2

Ursodeoxycholic Acid
3 open label studies (n = 24, 24, 31) One randomised (vs diet alone)

Improvement in aminotransferases
12 month study demonstrated improvement in

steatosis but not other histological features RCT trial now underway * Laurin et al 1996, Guma et al 1997, Ceriani et al 1998

NASH - DRUG TREATMENT 3 ANTIOXIDANTS

Betaine (methionine)
Improved LFTs, steatosis and inflammation n = 8, 12 months therapy, Abdelmalek et al 2000

N-Acetylcysteine
Improved LFTs n = 11, Gulbahar et al 2000

Vitamin E - Tocopherol
Improved LFTs over 4-10 months n = 11, Lavine et al 2000

NASH - DRUG TREATMENT 4 Insulin Resistance

Metformin
Improves sreatosis in ob/ob leptin deficient mouse Decreased Transaminases in non-diabetic subjects

with NASH compared with diet alone over 4m Reduced liver volume n = 20, Marchesini et al 2001 RCT planned by BASL

Troglitazone
Improved LFTs but no histological change n = 6, 4 months, Caldwell et al 2001

Management of NAFLD

NAFLD CONCLUSIONS

NAFLD is common A small proportion progress to cirrhosis NASH is the commonest cause of cryptogenic cirrhosis More information needed on prevalence, pathogenesis and natural history RCTs urgently needed - Metfomin, antioxidants and UDCA

Abnormal LFTs - Conclusions

Many abnormal LFTs will return to normal spontaneously An important minority of patients with abnormal LFTs will have important diagnoses, including communicable and potentially life threatening diseases Investigation requires clinical assessment and should be timely and pragmatic

GUIDELINES TO IX AND BX OF PATIENTS WITH ABNORMAL LFTs AND NO CLEAR DIAGNOSIS AFTER ROUTINE TESTS: WITH EMPHASIS ON FATTY LIVER AND NASH AS UNDERLYING DIAGNOSIS
SCREEN FOR XS ALCOHOL CONSUMPTION INTERVENE AND REVIEW

SCREEN FOR OCT/PD/RD DRUGS

SEROLOGICAL INVESTIGATIONS* NEGATIVE USS NO SPECIFIC DIAGNOSIS NO CLEAR CLINICAL (e.g. FHx A1 disease/xanthelasma/Signs CLD) ASSOCIATIONS WITH LIVER DISEASE

INTERVENE AND REVIEW

ABNORMAL CLINICAL SIGNS PRESENT

RE-EVALUATE DIAGNOSIS AND BIOPSY

NO CLINICAL SIGNS PERSISTENT ABNORMAL LFTs > 6/12

MEASURE: TG Chol. AST/ALT Ratio TFTs BP Fasting Blood Sugar Calculate BM1

NO CLINICAL SIGNS ALT >3x normal High risk LFT profile

IF ABNORMAL TREAT

CONFIRM TREATMENT EFFECTIVE

LIFESTYLE MODIFICATION MONITOR EFFECTIVENESS

LFTs NOT IMPROVED

LFTs IMPROVED RE-EVALUATE CLINICAL RISK FACTORS CONSIDER BIOPSY AND FURTHER IMAGING SEE GUIDANCE NOTES

LFTs WORSEN OR BECOME ABNORMAL

RETURN TO NORMAL OR IMPROVE

MONITOR

GUIDANCE NOTES
PREDICTIVE OF PATHOLOGY VS NORMAL: ALT > 2 x Normal AST: ALT >1 Age > 50 Low Platelet Count PREDICTORS OF NASH AND FIBROSIS IN PRESENCE OF NASH ALT > 2 x Normal AST > ALT Moderate Central Obesity BM1 > 28 NIDDM/Impaired GTT BP TGs. OTHER GROUPS WITH HIGH RISK PATHOLOGY: Raised Conjugated Bili with: ALT ALK P Consider: BX; MRCP; ERCP Any abnormality of ALK P in addition to abnormality ALT/AST Consider BX

SUGGESTED ROUTINE SEROLOGICAL INVESTIGATIONS: Alpha 1 AT; HAV; HBV; HCV; AIP and Igs; Fe Studies and HFE genotype; Caeruloplasmin; USS Fatty Change or Normal echo only; Bilirubin and haemolysis studies if appropriate - ANY ABNORMALITIES IN THESE PARAMETERS, RE-EVALUATE POTENTIAL DIAGNOSIS AND CONSIDER BIOPSY
N.B. THESE NOTES/ALGORITHMS ARE FOR GUIDANCE ONLY. THIS IS A MOVING FIELD AND DESPITE IMPROVEMENTS IN SEROLOGICAL AND RADIOLOGICAL TECHNIQUES, THERE REMAIN SMALL NUMBERS OF PATIENTS WHO HAVE SIGNIFICANT LIVER DISEASE WITH ONLY MILDLY ABNORMAL LFTs. THE ALGORITHM IS NO SUBSTITUTE FOR CAREFUL AND REPEATED CLINICAL EVALUATION AND CLINICAL VIGILANCE.