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Mia, Christmas in June 2010
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Discussion Starter · #1 · (Edited)
Mia had her annual this week and I received her bloodwork. Everything's fine but her ALT is slightly elevated (128; reference range 18-121 U/L) and nearly double last year's result. Her ALP and AST have also been trending upward but are still normal. GGT is normal and basically unchanged from two years ago. Thoughts?

ALT (reference range: 18-121 U/L)
2018 - 46 U/L
2019 - 67 U/L
2020 - 128 U/L

ALP (reference range: 5-160 U/L)
2018 - 17
2019 - 33
2020 - 36

AST (reference range: 16-55 U/L)
2018 - 28
2019 - 33
2020 - 41
 

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What does your vet say? From what I have read many things can cause elevated ALT. Poppy's was stratospheric when she was diagnosed with liver failure - much, much, much higher than that - and so were all the other results, including bilirubin.
 
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Mia, Christmas in June 2010
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Discussion Starter · #3 ·
In his initial email with the results he said that it looks fine. Since he didn't explain further, I asked about the trend lines, and asked about retesting in 6 months.

It's good to know that we're still well below "be alarmed" range.
 

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I think retesting 6 months is a good idea. Elevated ALT can be due to minor toxin exposure. I would not worry unless it continues to rise. Misha had a couple values like that. Slightly high but most likely caused by minor environmental exposures.
 

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Mia, Christmas in June 2010
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Discussion Starter · #5 · (Edited)
@fjm , the vet concurs with your opinion.
I certainly have no issue with rechecking that enzyme down the road, but it is a very slight increase. We don't get interested in that one unless it is more than double the high end of normal (ie around 240).
He has no issues with retesting, of course, but perhaps it's a little early to get concerned.

@Raindrops I'll keep that in mind. I still love your signature photo - Misha's joy is palpable.
 

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I think Poppy's was somewhere North of 500...!
 

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Mia, Christmas in June 2010
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Discussion Starter · #7 ·
Oh dear, @fjm , that would be quite alarming. Were other numbers elevated as well? I suppose it is a touch early to be concerned then, isn't it?
 

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I would say it's a little early to be concerned 🙂. Especially since it's only the ALT. I've seen results in the 800's that resolved even.
Never a bad idea to check again in six months of course. One thing to think about, when the ALT is high but ALP isn't (and if medications etc are not a possible cause) it can indicate Cushing's disease. Definitely not something to worry about now but in case it does continue to rise.
If you are interested in some 'heavier' reading, this is from the veterinary lab that my clinic uses. A good overview plus what other finding to correlate with.

Description: Alanine Aminotransferase (ALT) is a cellular enzyme released in response to injury of liver cells. ALT can also increase mildly with muscular injury and gastrointestinal disease.



Increased ALT



  • Liver disease
    • Infectious (e.g. leptospirosis, feline infectious peritonitis [FIP], bacterial cholangiohepatitis)
    • Inflammatory
      • Primary (e.g. chronic hepatitis, cholangiohepatitis)
      • Secondary (e.g. pancreatitis, gastroenteritis)
    • Toxic (e.g. NSAIDs, phenobarbital, methimazole, mushrooms, sago palm)
    • Vascular anomaly (usually mild elevations in ALT if any)
      • Portosystemic shunt (primary or acquired)
      • Microvascular dysplasia
    • Neoplasia
      • Primary liver cancer
      • Metastasis to liver
    • Liver hypoxia or hypoperfusion (e.g. severe anemia, congestive heart failure, shock)
    • Trauma
    • Inherited
      • Copper storage disease (e.g. Bedlington terriers)
      • Lysosomal storage disorders
  • Metabolic diseases with secondary hepatopathy
    • Hyperadrenocorticism (Cushing's disease)
    • Hyperthyroidism
    • Diabetes mellitus
    • Hepatic lipdosis
  • Skeletal myopathy (severe)
    • Ischemic myopathy (cat)
    • Muscular dystrophy (dog)
    • Trauma


Next Steps and Related Findings for Increased ALT



  • Liver disease
    • CBC:
      • May have regenerative anemia due to secondary gastrointestinal bleeding and/or anemia of chronic inflammatory disease
      • Decreased RBC, hematocrit
      • Initially increased MCV and RDW with regeneration, then developing microcytosis (decreased MCV) and hypochromasia (decreased MCHC) with severe or continued blood loss.
      • Decreased reticulocyte hemoglobin (RETIC-HGB)
      • Reticulocytes initially increased, but then decreased as iron deficiency or anemia of chronic inflammatory disease develops
      • Inflammatory leukogram
      • Platelets mildly to moderately decreased
    • Chemistry:
      • ALT increases with severity, may be increased >100-fold in acute disease, reducing with chronicity and/or loss of functional hepatic mass
      • AST, ALP, GGT and bilirubin variably increased
      • With loss of liver function, albumin, BUN, glucose and cholesterol may be decreased
    • Urinalysis:
      • Urine specific gravity often inappropriate in light of hydration status due to low BUN and/or altered thirst
      • Variable bilirubinuria
      • Variable bilirubin or ammonium biurate crystalluria
    • Bile acids - increased with diffuse or severe disease causing decreased liver function or acquired shunts
    • Coagulation panel - PT and PTT may be prolonged with severe disease
    • Abdominal imaging - abnormal liver size, structure or echogenicity
    • Investigate for underlying causes:
      • Infectious liver diseases
        • CBC - variable mild to moderate thrombocytopenia (especially with leptospirosis)
        • Urinalysis - proteinuria, glucosuria and casts may be seen with leptospirosis
        • Increased C-reactive protein (CRP)
        • Consider infectious disease testing:
          • Aerobic and anaerobic culture on fresh liver biopsy or aspirate
          • PCR or serology for infectious diseases (e.g. leptospirosis, toxoplasmosis, feline infectious peritonitis [FIP])
        • Liver cytology/biopsy - neutrophilic inflammation
      • Inflammatory
        • Increased C-reactive protein (CRP)
        • Liver cytology/biopsy - variable, lymphocytic/plasmacytic inflammation most common
        • Copper quantification or staining - may have secondary mild to moderate increases in copper in the liver
        • Evaluate for extrahepatic diseases which may cause secondary liver inflammation
          • Spec cPL/fPL test positive with pancreatitis
          • Abnormal cobalamin (vitamin B12) and folate with inflammatory bowel disease
      • Toxic insult
        • History/possibility of exposure to toxins or potentially hepatotoxic drugs (e.g. NSAIDs, phenobarbital, corticosteroids, methimazole/carbimazole, mushroom, sago palm, aflatoxin, ragwort (horses), xylitol, tetracycline, heavy metals, idiosyncratic drug reactions)
        • CBC - low white blood cell count with methimazole or phenobarbital toxicity
        • Urinalysis - Fanconi-like syndrome (glucosuria, ketonuria, aminoaciduria) may be seen with jerky treats or heavy metals
        • Phenobarbital concentrations may be predictive of toxicity, but some animals may have toxicity with therapeutic levels
        • Liver cytology/biopsy - liver cell necrosis with neutrophilic inflammation
      • Neoplasia
        • Abdominal ultrasound - enlarged or irregular liver, mass(es) within liver or diffuse infiltration may be seen
        • Chest radiographs - evaluate for metastasis to lungs
        • Liver biopsy or cytology consistent with primary neoplasia (e.g. hepatic adenocarcinoma, adenoma) or secondary metastasis
      • Vascular anomaly
        • Portosystemic shunt (PSS)
          • May be congenital or acquired secondary to end-stage liver disease
          • CBC:
            • Decreased MCV
            • Decreased reticulocyte hemoglobin (RETIC-HGB)
            • Blood film review - variably abnormal RBC morphology (poikilocytosis) e.g. target cells in dogs and keratocytes in cats, ovalocytes, acanthocytes
          • Chemistry:
            • Mild to moderately increased ALP, GGT and AST
            • Decreased albumin, BUN and cholesterol
            • Creatinine may be decreased (cats)
          • Urinalysis - ammonium biurate crystalluria
          • Protein C - decreased to <70% of baseline
          • Ammonia - increased
          • Bile acids (pre and post-prandial) - markedly increased
          • Abdominal radiographs - microhepatica
          • Ultrasound - decreased hepatic and portal veins, subjectively small liver, anomalous vessel may be detected, variable urolithiasis
          • Liver biopsy - microscopic bile duct proliferation, arteriolar proliferation, hypoplasia of intrahepatic portal tributaries, hepatocellular atrophy
          • Nuclear scintigraphy - calculated shunt fraction >60-80%
        • Microvascular dysplasia (portal vein hypoplasia)
          • CBC - usually normal
          • Chemistry:
            • Variably decreased ALT, ALP and AST (typically mild)
            • Variably decreased albumin, BUN and cholesterol (usually only decreased with severe disease)
          • Urinalysis - usually normal
          • Bile acids - variably deceased, usually less severe than with portosystemic shunt
          • Protein C - typically >70% of baseline
          • Abdominal radiographs - typically normal
          • Abdominal ultrasound - typically normal appearing liver and vasculature, variable secondary urolithiasis
          • Liver biopsy - unable to differentiate from changes seen with portosystemic shunt. Changes may be present in only some liver lobes.
          • Nuclear scintigraphy - calculated shunt fraction <60%
  • Hyperadrenocortism (Cushing's disease)
    • CBC:
      • Stress leukogram:
        • Increased neutrophils and monocytes
        • Decreased lymphocytes and eosinophils
        • Normal white blood cell morphology on blood film review
      • Increased platelets, +/- plateletcrit, MPV and PDW
    • Chemistry:
      • Increased ALP typically higher than ALT or GGT
      • Glucose variably increased
    • Urinalysis - variable proteinuria
    • Urine protein: creatinine ratio may be mildly increased
    • Assess history for recent glucocorticoid administration (including topical)
    • Abnormal adrenal function tests:
      • Low dose dexamethasone suppression test
      • ACTH stimulation
    • Ultrasound shows enlarged adrenals and diffusely hyperechoic enlarged liver with smooth margins.
    • Liver cytology/biopsy - vacuolar hepatopathy
  • Feline hyperthyroidism
    • CBC - mild increase in RBC, hematocrit and hemoglobin
    • Chemistry:
      • Increased ALT
      • Variably increased ALP, phosphorus and glucose
    • Urinalysis:
      • Urine specific gravity variably <1.035; inappropriate concentration in light of hydration status in some cats
      • Variable proteinuria, especially with secondary systemic hypertension
    • Free T4 - increased
    • Endogenous cTSH - decreased
    • Blood pressure - secondary systemic hypertension common
    • Cardiopet proBNP test - increased with secondary cardiomyopathy
    • I-131 thyroid scan abnormal
  • Diabetes mellitus
    • CBC - variable nonregenerative anemia (with chronic disease) or increased RBC, hematocrit and hemoglobin with dehydration
    • Chemistry:
      • Increased glucose, ALP, ALT and cholesterol
      • ALP increases typically greater than ALT
      • If ketoacidotic:
        • Increased SDMA, creatinine, BUN, anion gap
        • Decreased TCO2, sodium and potassium
    • Urinalysis:
      • Glucose and variable ketonuria
      • Bacteriuria and increased white blood cells may be seen with secondary urinary tract infection.
    • Fructosamine - increased
    • Blood gas - metabolic acidosis with DKA
    • Evaluate for predisposing or secondary conditions:
      • Spec fPL or Spec cPL test - increased with concurrent pancreatitis (especially cats)
      • Urine culture and MIC susceptibility - positive with secondary urinary tract infection (common)
      • History of recent glucocorticoid administration
  • Hepatic lipidosis (cats)
    • CBC - nonregenerative anemia of chronic inflammatory disease
    • Chemistry:
      • Increased ALP > GGT; GGT usually normal to only mildly increased (unless concurrent inflammatory disease)
      • Increased bilirubin
      • BUN decreased
      • Variable cholesterol and albumin
    • Urinalysis:
      • Variable; often inappropriate concentration in light of hydration status (urine specific gravity <1.035)
      • Variable bilirubinuria (follows increased serum bilirubin)
    • Bile acids - may be increased with severe disease; not helpful if concurrent elevated serum bilirubin
    • Coagulation panel - PT and PTT may be increased with severe disease
    • Radiographs - enlarged liver with smooth margins
    • Ultrasound - diffusely hyperechoic liver; abdominal effusion may be present if secondary to pancreatitis
    • Liver cytology or biopsy - severe vacuolar hepatopathy
    • Investigate for underlying causes:
      • Spec fPL test increased with pancreatitis
      • Cobalamin (vitamin B12) and folate variably abnormal with inflammatory bowel disease
      • History of stress or household changes


Additional Information



Physiology



  • ALT is a hepatocellular enzyme
  • ALT is also known as serum glutamic-pyruvic transaminase (SGPT)
  • The enzyme is almost exclusively found within hepatocytes, so serum increases are highly specific for hepatocellular injury in dogs and cats (there is only a minor contribution from skeletal muscle and red blood cells).
  • The magnitude of increase is related to the number of hepatocytes affected, but does not necessarily reflect severity of liver damage nor predict reversibility.
  • The serum half life is 2-3 days for dogs; reductions occur over 1-2 weeks with cessation of hepatic damage.
  • The serum half life is 3.5 hours in cats, therefore minor elevations are significant in this species.
  • The hepatocellular level of ALT in horses is very low, hence ALT is of limited value in this species.


References



  • Ettinger SJ, Feldman EC, Cote E, eds. Textbook of Veterinary Internal Medicine, 8th ed. St. Louis, MO: Elsevier; 2017.
  • Lattimer KS, Mahaffey EA, Prasse KW, eds. Duncan and Prasse's Veterinary Laboratory Medicine: Clinical Pathology, 4th ed. Ames, IA: Blackwell; 2003.
  • Stockham SL, Scott MA. Fundamentals of Veterinary Clinical Pathology, 2nd ed. Ames, IA: Blackwell; 2008.
  • Willard MD, Tvedten H, eds. Small Animal Clinical Diagnosis by Laboratory Methods, 4th ed. St. Louis, MO: Saunders; 2004.


Last updated 1/12/2018
 

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If I remember correctly, my toy poodle’s ALT values were something like 2000+ at the end of his life when he had liver issues. I do remember the vet saying that it’s normal for it to fluctuate a good bit due to environmental factors (but of course not as high as 2000, which was a result of a mass on his liver).
 

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Mia, Christmas in June 2010
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Discussion Starter · #10 ·
Thanks for sharing your experience, @HannahMarieJ . It would seem that Mia's numbers aren't particularly worrisome at all.

@Starvt , thanks for the outline of the decision tree; it lays to rest any worry about unknown possibilities. Her other numbers are still well within the normal ranges, so I'll just keep an eye out for now.
 

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Yes, all Poppy's results were off the scale, and it was very obvious that something was extremely wrong. Her vet phoned me the moment he saw them, and started therapy immediately. Some are still very high, some have dropped back to normal, but the liver damage is permanent. She is very happy though - we are managing it with drugs and diet, and enjoying each day as it comes.

I really don't think you need to worry - keep an eye on it by all means, but it needs to be read in the context of all the other results, and those are fine.
 
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Mia, Christmas in June 2010
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Discussion Starter · #13 ·
I wondered that as well, PTP. She's also eaten some unusual things in the last week or so. I didn't ask directly, but rather than speculate, I put a note in my calendar to retest in six months. You know as well as I that sometimes medicine is slow to respond to a train barreling down the tracks, so I'm trying to put myself in a position to sound the alarm if needed.
 
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