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ALT & AST and the "normal range"
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ALT & AST and the "normal range"

Hello again. I'm making up for a long silence in the forum by posting a bunch of things all at once. If anyone objects to this, or is getting tired of seeing my photo in the thread list, sorry about that. [I'm trying to be nice. My real reaction would be "Tough!".]

This is about blood test scores of hepatic enzymes ALT and AST and what is commonly called "the normal range" of these. The so-called normal range is often given on the test results, usually as something like 2-to-40. Different labs differ in their idea of what the normal range is, which is a clue to its uncertainty, the subject of this note.

If you get back an AST score of 45 and the lab gives 2-to-45 as the normal range, does that mean your hepatic ennzymes are leaking out of hepatic cells and into the bloodstream at a normal (undiseased) rate? The answer is probably "No". If you know someone who has had a blood test with hepatogram, someone who is in good health and isn't suffering from any liver dysfunction, ask them to show you their test results. See what their AST is. I'll bet it's between 2 and 20. I've checked with a number of friends and that was what I found.

Dr. Frider, the head of hepatology at a large public hospital here in Buenos Aires, agrees that the normal range does not really go up to 40 or 45 but more like 20. Here's an article he and others published on this subject as well as some other interesting things:

How to distinguish normal liver from chronic hepatitis in anti-HCV positive individuals with normal alanine aminotransferase levels.
Silvia Sookoian, Gustavo Castaño, Bernardo Frider, Diego Flichman. Unidad de Hepatología, Departamento de Medicina Interna, Hospital Dr. Cosme Argerich, Buenos Aires, Argentina. (ssookoian at intramed.net.ar). Medicina (Medicina (B Aires)) Vol. 62 Issue 3 Pg. 226-30 ( 2002)

The upshot of this is that some people with hepatitis C aren't getting diagnosed for it because a routine blood test that gives AST as 45 or 50 is being interpreted as "within the normal range" or "close to normal". This is exactly what happened to me in 2005, and again in 2007.

This is definitely not cool, but - need I say it? - it's the sort of thing we've come to expect from you-know-who [that's right, the sawbones mob and the pill pusher gang]. Like: What epidemic?. . . and: There aren't so many HCV infectees. . . and: The numbers are going down [translation: Our hugely expensive meds are working to combat the threat of HCV pandemic].

As my father used to say, you can't believe everything you read or maybe anything you read [even on blood analysis results].

Cheers!

Mike



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16 Comments Post a Comment
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Avatar_m_tn
I would imagine "normal" ranges have been established across millions of tests done over many years. Don't see much wrong with that approach, since there's no better evidence than empirical. Bear in mind that "liver enzymes" are not isolated, nor produced solely in the liver in any sense of the word.

Bottom line: If you've ever had risky behavior, get a test. That's how it's diagnosed.

RBW
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Avatar_f_tn
Mike, I think you're going to have to change your "mood".  :)

I tend to agree that those in the upper limit should get tested but I differ in that it's negligent or a conspiracy.  Just simply not widely accepted or recognized as yet and this could change over time.  And I could be simply wrong.  I'm only basing it on the fact that my own liver enzymes were mid 40's and I was Stage 1.  Now that I'm SVR, my liver enzymes are in their teens.  

They have to set the limits somewhere and I don't think they purposely set out to dupe the public when they set them.  They may get adjusted over time though as new information comes to light.  Your own particular biases and prejudices may cause your perspective to be different, however.  I'll respectfully say you gotta watch about projecting those biases onto other people and taking a "you're either with me or against me" point of view.  Sometimes it's just simply neither....hm?  

Trish
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979080_tn?1323437239
Hey Mike,
I am happy for your recent good results. Lower enzymes , good doppler ultrasound
that is all great and reminds me how elated I was when I did various non traditional
treatments and got my ALT /AST down to 29/14 while being infected.

Cheers
b
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148588_tn?1407125204
Pre-tx ALT/AST consistently 60-80 range.(This is why my GP had me tested in 1992.)

EOT to one year post-tx consistently high teens to low 20s on a 0-40 'normal' scale.

One year post started taking a variety of meds for hypertension etc.(see DD's post-tx thread.) ALT/AST crept up to high 'normal' and occasionally even low 40s, triggering the dreaded, automated 'values out of normal range' letter in my mailbox. Current GP said, "Don't worry about it."

The year I turned 50 (coincidence?) 'normal' suddenly became 0-55 and my occasional low 40s suddenly became normal. (Since that time they've drifted back down to the 20s again.)


By aging a year, I became 'normal'. That's my story and I'm sticking to it.
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789911_tn?1368640383
I am one of those that went to the doc every year for the physical, etc.  and as I looked back on my blood work I could see the ALT AST creeping upward  from the teens then consistantly high normal and then even out of range high but only slightly,  I always asked about my liver functions and no one ever took notice.  I could have found out years before i did, if someone had been smart enough to run it.  I should have had a full hep panel.  Just courious, how did a non a non b show itself back in the day?   they would have at least found out I was not immune to hep b even though I was immunized as a kid supposedly.       Its a virus filled world out there.  They had no problem running a HIV test on me.  Why dont they just put the two together?  HIV/HCV..... I have never had a good trust of the med community and now im about to lie down and let them have their way with me for the HCV.  Hope they do it right this time.  
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475555_tn?1303617674
The experiences and opinions of everyone who has posted here, except for RobertBeWell, coincide with my own and all the poeple I know. That is, that normal ALT is really in the teens or low twenties, not 40 or 45.

Okay, maybe it's not a conspiracy, but the fact is that everyone, and there are a lot of us, who were not tested for HCV because our ALT was "only" 40 or 45 have been cheated out of years when we could have been making decisions about treatment and/or doing alternative meds like antioxidants.

I think I have good grounds for being angry about this. If I had been diagnosed when my first bloods showed ALT 40, I could have started my diet and antioxidant regime years earlier and maybe my fibrosis would still be F1 instead of progressing as it has to F2 or F3.

his3707 seems to have had the same experience I did. I feel angry for him/her, too, and for everyone else for whom medical practice hasn't worked right.

What's the cause of this bad situation? The doctors are obviously screwing up by not testing people with ALT above, say, 25. The test is simple and cheap. It's just a quickie ELISA antibody test. Why aren't we getting it when we should?

I hope Trish is right and that this awful situation will be corrected. But what are they, the doctors, waiting for? I think we have a right, even a duty, to ask this question.

I had a long consultation two years ago with Dr. Frider, the author of the above article that comes to the same conclusions about the true normal range of ALT. He said flat out that my MDs were negligent in not testing me as soon as they saw that my ALT was near the ULN [Upper Limit of Normal]. He was as mad as I am. He told me he sees too many patients whose diagnosis was put off way too long because of negligent MDs who sent them for blood tests and then misinterpreted the results.

Probably there are thousands of us who are in this position. What's the explanation? Are the MDs blind? Don't they care? What's the answer?

For me, the answer is to speak out. Maybe others just accept everything that MDs do or don't do because they are MDs, some sort of higher beings who can't be wrong, but I don't believe that. I think many if not most of them are stymied by infections like HCV and are making mistakes that are causing unnecessary suffering, like failing to administer HCV tests when they are clearly indicated by high ALT scores.

These mistaken practices have got to stop.

Mike
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475555_tn?1303617674
Thanks for the good words. I hope this regime keeps working. My situation has changed radically since I started the diet and antioxidants, and my mood has imporved 100%, in spite of what Trish says [grin].

I hope you are doing well, too.

Hugs!

Mike
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789911_tn?1368640383
I am HIS .  I  am a girl.  HIS is Christ I belong to.   Now then,  Until they get a HCV antibody test that is easy and inexpensive, the docs wont give it.  My doc admitted it was a $$ issue for the insurance companies.   If the doc tells the patient there is a test for HCV and the patient has risk factors that could warrant one,  then the insurance companies will have a fit paying for all that.  We all know that elevated ALT and AST isn't necessarily  a factor for determining liver damage, and could be caused by other factors, muscle damage for one, but a chronic elevated level should be considered.  I think  since i was on a statin that an elevated level might be expected?  Not sure about that but since I had to have my LFT's run every 6 months to a year while on a statin that is what led me to believe that also.  
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475555_tn?1303617674
I don't know what your situation is (where you live, what insurance you have, if you are under the care of a hepatologist or just a gastro MD, et cetera), but getting an antibody test for HCV is a simple, cheap, and standard routine in most places. I was diagnosed HCV+ from an antibody test that was administered to me, together with an HIV test, by a gastroenterologist just as standard routine with a blood test, because I had intestinal problems.

I don't believe there can be money issues, as the HCV antibody test is really very simple and cheap. And it's a no-brainer to have it done along with a blood test with hepatogram if the patient has elevated ALT (not necessarily AST). Elevated ALT is at present considered to be anything at or above the ULN (usually 40).

This is the situation in Argentina and I believe also in the U.S. and Europe.

However, the doctors are not paying enough attention to the ALT scores. They are letting patients with liver trouble slip by without the HCV test. This is the problem.

Mike
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789911_tn?1368640383
Hi Mike, I live in the US and have insurance right now.   (Still have a pile of medical bills)    And I am under Dr. Ghalib in Arlington TX.  She is supposedly good and is a transplant hepatologist.   Of course I mainly see her nurse practitioner.    I am hopefully starting the Telaprevir dosing study by may 15.  Just went today to make sure my retinas were securely attached at the eye doctor and all is left is biopsy on Friday.  
yes your really correct.  I guess though the anti body test is cheap but the RNA test is what is expensive right?  Is that what is the hold up then? As far as money issues for the Insurance companies.   Isnt it always about the money?  I have told my reg doc and my gyno doc the need to test all expectant moms anyway,  I bet they dont.  It makes no sense to me never has.  Especially when you go to your doc and say you want to be tested for everything like I asked for when I wanted to have kids.  They didn't test me for what should have shown as Non a Non b  in 1995 wouldn't non a non b have shown up somewhere?   How did they determine that back in the early 90's.    They did do a Hep panel on me and  Also again in 1999.  My oldest son has the antibody for HCV.   I have told friends to get tested and many as I have mentioned before came back and said my doc said my alts and ast numbers were fine.  Even today, the docs are still relying on that for any suspicious reason to test someone for liver disease.  You get one rat's hair width away from a doctors specialty and they dont know how to act.  Just like a comedian in real life.  They dont know what to talk about.   I got attacked by chiggers this weekend while hiking and showed my liver doc and she acted like chiggers were from another galaxy.  didnt have a clue what to do about them.    go figure
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475555_tn?1303617674
Yes, it's the RNA test that's expensive, although even that has been somewhat automated and costs a lot less than it used to. However, it is used only to confirm the antibody test, which by itself is sufficient to diagnose for HCV. And it is cheap and easy. If it weren't for the AMA, the antibody tests for viruses like HCV and HIV could be made available over-the-counter. The instructions are simple and easy to do.

The whole testing thing is a complete mess. And it isn't going to change until the function of medicine is seen as helping patients, not making doctors rich, as it is today.

I don't remember how non-a, non-b hep was diagnosed before the antibody and RNA tests were developed, but I believe it could be diagnosed back in the 90s.

Your son with the anti-HCV antibodies, has he had an RNA test to determine whether or not he cleared the virus? Unless liver disease can be clearly determined by a blood test or ultrasound, the RNA test is the only thing that I know of that can clear up the question of whether or not he still has HCV in his body. You need to know that as soon as possible. If he does still have HCV, it would obviously be a mistake to wait for symptoms. He could be F3 before symptoms show up.

Good luck with the Telaprevir dosing study. I hope you get the right dose, and that you avoid the worst of the side effects. Do you know if they are going to give you helper drugs in the test if you get anemic or other stuff happens? One of the main questions is at what level of platelets and hemoglobin they start cutting down the doses of the therapy drugs. There's a list of questions that people going into trials need to ask. It's been posted in this forum a number of times by different people.. But maybe as you have already signed up you won't get another chance to ask them. I don't know. All trials have their own rules.

Keep me posted on your biopsy and the trial. I am very interested to see how it goes. If you don't post it to the forum, at least send me a message now and then to let me know what's happening. Okay?

Cheers!

Mike
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1253246_tn?1332076910
My Gyno is the one that discovered my hep C.She tells me that alot of people DONT want the tested for hep c and dont want to know if they have it...you have to ask for the test and if you say no to it they have to comply with your wants.. cindy
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Avatar_m_tn

Thats a good point Cindy... my primary care doc told me the same thing .that many people  with somewhat higher than normal liver enzymes are told they should get screened for the hep"s and many patients flat out refuse.

Hopefully now that meds are going to be more efficient  those that do not want to be tested will think  twice.
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1318202_tn?1274311427
My enzymes levels were in hundreds (~700) for many years. Diagnosed with hep-c, treated and now I am clean for more than 6 mo. Currents levels 30-40, so I don't think 20 or 40 is the big difference. When in hundreds, go to the doctor.
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789911_tn?1368640383
Yes, I did have the RNA test done on my son and no virus detected.

As far as I have been hearing there is no difference in dosing 3 times a day or 2 times aday.  you get the same amount.   They want the twice a day on the label.  I would like the 3 times a day.  SLAM SLAM SLAM   Thats a grand slam!  
I will keep you up to date Mike and also the forum because this is why we're here to learn from what others are doing and not doing.    

its hard to believe that people would not want to know if they had a disease that could easily be tested for.  I guess some people also feel like if they get diagnosed with something they might not be able to get insurance.  Or they would be forced to do something about it.  I have never heard of that before.  But at least it was offered.   It was never offered to me or explained in anyway.  
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475555_tn?1303617674
Yes, it's hard to understand why people would refuse to be tested. Must be the ostrich syndrome. Obviously a big mistake, because the sooner you know the sooner you can do something abbout it.

Mike
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