AST - ALT levels not very reliable???

Hello everyone, I am new to the forum and have been reading some posts and read that AST and ALT levels are not a great indicator of how my Hep C is doing? I was diagnosed 6 years ago (but think I've had it for about 16-17 yrs.) and had a Ultrasound, (looked good), a liver biopsy at that time (looked good) and also my viral levels were very low at that time, but my AST and ALT levels were up a bit. OK, now over these 6 years I have had another ultrasound, still good (about to have another) and my AST & ALT levels monitored every six months to a year. Well they had been steadily on the rise but last Oct (2002) they had dropped down to normal. I took this as a great sign and was very estatic about it. Now I'm hearing this means not alot. I am going for blood tests Tues, I am going to call my Dr. Monday and ask her to get my Viral Load and Genotype at this time too. As of now, I have had no treatment whatsoever. But I am feeling pretty well. Am I a total idiot for listening to my Drs. I mean jeez, I've been going to the Mayo Clinic, don't you think if treatment now would help they would recommend it? I have'nt been going to all these tests for the peppy conversation and relaxing atmophere, I thought I was going to keep close watch on this thing. Do I need more tests?

[GreatBird]

I'll jump in here and hope I don't put my foot in my mouth. :)

AST and ALT numbers aren't reliable in some situations: they aren't a reliable way for a doctor to screen for HCV (i.e. some doctors don't think a patient might have HCV because of normal liver function numbers), and they aren't an accurate way of gauging liver damage. Someone can have normal numbers for years and have a biopsy that's a stage 3, or 4. In fact, I've read that seriously compromised livers can't crank out the enzymes so someone with cirrhosis can have normal levels just because their liver is not doing well.

But since you have been keepin an eye on your ALT and AST progression, I would *think* it signifies, especially as you are watching it change and you know (by biopsy) what condition your liver is in. However, if its been more than five years since you've had a biopsy, you should consider having another one to see if it has changed.

The thing is, we all handle HCV differently. Our genetics are different, our diets are different, other challenges to our health are different, so there is no real way you can predict how you will do based on anybody else. Even statistics won't tell you how you will do--although they can tell you how you will *probably* do.

Having HCV for 16 years isn't a long time. There are many on this forum who have had it considerably longer. In my completely non-qualified opinion, its not long enough to see how your liver handles the virus long-term. If you had had it for 25 years or more and were just stage 1, then it would seem to me you are handling it OK and could easily wait for some easier treatment. So, I encourage you to keep an eye on things, and it sounds like you are doing that.

Do you have copies of all your records? You didn't say exactly what stage/grade your biopsy is. Regardless of the qualifications of your doctor(s), I'd make sure I'd actually read the report and would want something more concrete than "looked good."

And welcome to the forum. :)

[latrobe]

i'll jump in also, and probably will put my foot in my mouth, but we're allowed to that here.
i don't think the doctors did a bad thing by not treating...the peg-intrefrons havent been around all that long and especially in combo form.
so maybe it's not such a bad thing to haave delayed.
i agree, that you need more current information--genotype and biopsy--genotype is interesting to know, but really is of most use when you and if you decide to start treatment.
so don't be too mean to your doctors. if you decide to treat , you wnat them on your side to help you deal with the vagaries of treatment.
good luck,
macky

[tigerdream]

Hello again, and thank you GreatBird and latrobe, I don't have any copies of my records, I guess it is really my own fault that I don't have more information about the genotype I have and that I have not really kept alot of records of all my test results, stick your head in the sand thing I guess. In the beginning it was kind of like Docs would say "Looks good" and I would run through the wall and away from clinic fast as I could, not thinking about it again till I knew I had to. But anyhow, I really appreciate your input as I have never talked to anyone that had any real knowledge or just general info. Mostly I have looked into various med sites to get what tid-bits they could provide. It is gr8 to see all of you keeping positive attitudes, supporting each other, being there for when one of you is down. I have close people in my life but don't feel like I can talk freely with them, I feel like it might upset them to speak of my fears, the dreams I don't want to lose, the uncertainty of the future. Although I am doing well now (I think) I sometimes feel like I want to talk about it, to get it out of my head a bit, maybe just to be reassured sometimes I guess. I'm sure I will be posting plenty of questions here as I am a very curious cat. I welcome all the responses I can get and THANK YOU!

[tuna]

Keep asking questions, This sight is a great place to learn, their is a lot of hep people on this sight that can answer any of your questions! wk 5, 1b, stage3.

[Galen]

Welcome to the forum.
It sounds like your doctors are doing a good job of monitoring you, though I also think you need more info about that bx than "looks good".  I've had HCV for over 30 years and am grade 1 and have not had elevated liver enzymes since 15 years ago.  If you were very mild disease and have been monitoring your levels every 6 months, it is a good bet that your doing ok.

[fatboy]

ALT & AST levels indicate (in most instances) current levels of damage activity. A biopsy will reveal the historical record, so to "speak," of the damage done to the liver.

Scarring can be a cumulative thing if the damage outpaces the liver's ability to heal itself. I don't know of any way to guesstimate this activity based upon ALT/AST levels.

You are doing the right thing by going to a doc to get answers.

God bless!  -Michael

[mikesimon]

Have you read the articles which indicate that the ratio of ast/alt can uggest cirrhosis? The greater the ratio the more likely cirrhosis. Mike

[mikesimon]

I believe I saw it on medscape. If I recall correctly as the ast/alt ratio increased so too did the likelihood of cirrhosis. I think over 1 was the turning point. I don't recall the exact context. If you search medscape and don't find it let me know and I'll try to get it. I think it was just a short article and it may have originated in Italy or some other obscure country. Kidding - sort of. Mike

[fatboy]

No, I haven't. Is it recent? I've been rather uninspired, uninvolved, incurious, and just plain 'ol out of it as far as participation here on the forum and keeping up to date with HCV news.

Can you tell me where it might be found - or should I go a huntin'? :)

I'm soon ready to unveil my new forum alias, MichaelT, as soon as can wipe the autosave of my current alias/password on several PCs/workstations I use. This is the most excitement I've had in, gosh, weeks!

How are you holding out? You seem to be doing well - at least you "sound" okay.

I've been itching to create a neural net against illness data and see what pops up - ALT/AST ratio is something that would have stood out as a cirrhosis predictor easily. Problem is getting hold of a goodly number of data of the desired type - know any sources?

[cmurphy]

I too have read that if the AST is higher than the ALT it can be an indication of cirrhosis.  Do you know if that is always the case?  I did not have a biopsy since I am a 3a, and my ast/alt ratio was 32/30 before I started tx.  My doc and I decided to wait for a biopsy to see if I responded to tx or not.  What do you think?  Should I be concerned?  Thanks for your advice - Cheryl

[willing]

Hi, the predictive value of the ast/alt ratio actually seems to be a matter of some controversy : references 33-37 of this <a href ="http://hepatology2.aasldjournals.org/scripts/om.dll/serve?action=searchDB&searchDBfor=art&artType=fullfree&id=ajhep036s152"> biopsy paper</a> duke it out. I'm too fogged to make sense of any of it today but would be interested to hear the current consensus if anyone wants to wade through them.

Cheryl - strictly based on the stats, there's not much grounds for getting a baseline biopsy as a 3. However on the emotional side I think knowing the extent of liver damage make a huge difference (remember Bicky's post from a couple of weeks ago). If the biopsy indicates significant damage you may want to push past the 24 weeks (particularly if you're not clear at 12). A longer tx doesn't promise a significant improvement in SVR for 2/3s but maybe worth doing on emotional, "doing everything you can" grounds if fibrosis is extensive. Also, there are a number of "biochemical" surrogates for biopsy as a cirrhosis diagnostic which are fairly well established (I think layla posted an link to one earlier today) - however they won't give anywhere as accurate an answer.

[CARUU]

I got my results from the doc yesterday.  
I'm 2a and 140,000 IU/mL
He is not going to do a biopsy at this time because I had gallbladder surgery in April and the doctor noted liver normal and because there is some risk with the biopsy.  Does this make sense?  I'm going back on Sept. 16 to talk about starting tx.  I am working on getting my emotional and physical strength up before starting.  Any suggestions are appreciated.  caruu

[mikesimon]

I would be pleased with the type and load. If you are going to start tx anyway I wouldn't even want a biopsy. Your chance of clearance is very good and there are risks when you have a biopsy despite the fact that the vast majority go without incident. I recall GI.PA stating that she doesn't biopsy type 2s if they are committed to treatment unless there is other reason for concern. Since their chance of clearance is high and they are going to do tx there is no reason to biopsy. Maybe she will address this issue and give you more comfort about your doctor's advice. I'd just take it and plan to start tx as soon as possible. And get rid of this virus now. Good luck. Mike

[CARUU]

Thanks for the encouragement.  If I have to have hepc, I am lucky to have type 2a, from what I have heard and read.  I'm not looking forward to treatment, but I am happy to know there is a good success rate with it and that I may be able to GET RID of the dragon and get my life back. caruu

[cmurphy]

Mike - thanks for your comments.  I have actually seen this reference for AST/ALT ratio in several places:

"Alanine aminotransferase (ALT) levels are usually higher than aspartate aminotransferase (AST) levels, but that finding may be reversed in patients who have cirrhosis."
http://www.niddk.nih.gov/health/digest/pubs/chrnhepc/chrnhepc.htm

"ALT is elevated to a lesser degree than AST in alcoholic liver disease and cirrhosis, passive congestion, bile duct obstruction, or metastatic tumor to the liver (AST/ALT greater than 1.0)"
http://hepatitis-central.com/hcv/labs/altast.html

"In many cases of liver inflammation the ALT and AST activities are elevated roughly in a 1:1 ratio.  In some conditions, such as alcoholism or shock liver, the elevation in the serum AST level may be higher than the elevation in the serum ALT level."
http://janis7hepc.com/Labs.htm

I have not seen a study that made these findings.  However, this is on the list to talk to my doc about after my 12 week tests next week.  My question is that since we did not do a biopsy how do we know I don't have cirrhosis?  and if I clear, does it matter?

Anyway, you are great and I appreciate the information.  I hope you don't feel there are topics that shouldn't be posted.  But, I am sorry if I horned in on your discussion with fatboy.  Thanks again, Cheryl

[mikesimon]

No, I wouldn't be concerned. I haven't seen any real data that supports this premise except for that article and maybe a reference or two to it. And I seem to recall that the article was in a special context but I can't remember what it was. I'll try to find it for you. In the meantime why don't you just do the tx and see how things go. I am reviewing my numbers for the last 3 years and I see that my ast has been higher than my alt on several occasions. 9/9/2002 ast 24 alt 26; 9/25/2002 ast 28 alt 26; 10/7/2002 ast 20 alt 17; 10/24/2002 ast 28 alt 35. You can see that these numbers can fluctuate and I know I do not have cirrhosis. There's enough to worry about right now without borrowing trouble. I remember reading that article and thinking that I should not post it for the reason that it might cause anxiety and stress. I just wanted Fatboy's opinion on it or I wouldn't have mentioned it. Basically I don't really buy that theory for hep c patients in general. Don't worry about it Cheryl. Your numbers are so close anyway that I wouldn't be surprised if that same blood sample were tested again the numbers would be different due to error. Really for a person not yet on tx your numbers look really nice. I've had some high ones that you wouldn't even want to see. Good luck. Mike

[CARUU]

My PCR, genotype test also included an Antimitochondrial Ab (ANA), Qn  The result was <1:20  Is this the biochemical surrogate you referred to?  My doctor looked at this as being an indication there is minimal, if any, liver damage.  He doesn't recommend a bx at this point (I'm 2a, 140,000 IU/mL).

[willing]

yes - the test for mitochondrial antibodies indicates liver dysfunction. However it seems to be used in liver testing primarily a diagnostic for primary biliary cirrhosis (not hcv-induced cirrhosis) <a href="http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T1B-4908YGT-W&_coverDate=07%2F05%2F2003&_alid=108911435&_rdoc=1&_fmt=&_orig=search&_qd=1&_cdi=4886&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=892e762e76f3dc4638d0515295b8757d">review</a>  It's not included among the blood-sample markers commonly used to assess hcv-related fibrosis (see <a href="http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T1B-4908YGT-W&_coverDate=07%2F05%2F2003&_alid=108911435&_rdoc=1&_fmt=&_orig=search&_qd=1&_cdi=4886&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=892e762e76f3dc4638d0515295b8757d">list</a>.
Perhaps your doctor was specifically concerned about PBC ? Erin may be able to provide more information about this test - sorry I can't be more helpful.

[willing]

sorry -posted the wrong <a href="http://hepatology2.aasldjournals.org/scripts/om.dll/serve?action=searchDB&searchDBfor=art&artType=fullfree&id=ajhep0360s57#head3">list</a> of fibrosis-related serum markers.

[CARUU]

Thanks for the info.  I don't know for sure why he did the ANA.  I had my gallbladder out in April and continued to have some RUQ pain.  Maybe that's why.  I know everyone says we need to learn as much as we can and be in charge, but sometimes I feel like just leaving it up to the experts and focusing on what I like and do best.  I really like this forum, but have to be careful to balance the time I spend thinking about Hepc/treatment and everything else I have to do.  The info. here and, especially, the support is great.

[CARUU]

Thanks for the info.  I don't know for sure why he did the ANA.  I had my gallbladder out in April and continued to have some RUQ pain.  Maybe that's why.  I know everyone says we need to learn as much as we can and be in charge, but sometimes I feel like just leaving it up to the experts and focusing on what I like and do best.  I really like this forum, but have to be careful to balance the time I spend thinking about Hepc/treatment and everything else I have to do.  The info. here and, especially, the support is great.