Undetected Alt Ast

[gsx1250fa]

Hi all. I'm on my 4th Tx attempt in 3 years. I am Geno 1a stage 5 (of 6 ishak scale) beginning cirrhosis. This Tx time the all oral sofosbuvir/gs-5885 with riba (12 weeks). My Alt and Ast before Tx were Alt-270 and Ast-213. I reached UND for the first time ever at week 4 and just got my week 8 results back still UND. My Alt was 79 and AST 57. I was hoping fmy Alt and Ast would drop to normal, but they haven't. If I am able to stay UND and reach SVR is there a possibility my levels will slowly drop back to normal over time?  My Doc said I am on the right path and the main concern right now is staying UND and reaching SVR. Has anybody else reached UND and still had elevated Alt and Ast scores? thks

[pooh55811]

I had an excellent drop at week 4 but was still Detectable <43. I was Undetectable at weeks 8, 12, 16, 20, 24, 28, 32, 36, and 48. My week 48 test was able to detect down to 5 but it was Undetectable. Then I was Undetectable at 12 weeks post end of treatment. I am due for my 24 weeks post end of treatment VL and should have it in a few days. But, since I was UND at 12 weeks post end of treatment, I have a 99.7% chance for SVR.

Treatment Drugs: Interferon, Ribavirin, Incivek
Starting VL was 14,400,000  (Result in Log IU/mL= 7.16)

My tests read as follows (this is the exact format and wording). You can see that each test clearly states if I was Detected or Undetected. The 4 week test clearly states that I was Detected but less than 43:

Week 4 VL:  
HCV RNA  Detect/Quant
DETECTED
Reference Range: Undetected
Unit: IU/mL
(Note)
HCV RNA  DETECTED, but less than 43 IU/mL (1.63 log IU/mL)
This assay cannot accurately quantify HCV RNA blow this level
Result in log IU/mL = <1.63
Quantification range of this assay is 43 IU/mL to 69,000,000 IU/mL  (1.63 to 7.84 log IU/mL)

Week 8 VL:  
HCV RNA  Detect/Quant
UNDETECTED
Reference Range: Undetected
Unit: IU/mL
(Note)
Result in log IU/mL is UNDETECTED
Quantification range of this assay is 43 IU/mL to 69,000,000 IU/mL  (1.63 to 7.84 log IU/mL)

Both of these tests were performed by the COBAS AmpliPrep/COBAS Taqman HCV Test (Roche Molecular Systems, Inc.)


Hope this helps. If your test does not have Detected or Undetected clearly written on it, you could call the lab directly and ask them (the lab supervisor) to explain the test to you . Ask the lab sup if your test means you are Detected but below 40 or if it means you are Undetected.

Best of luck.

[48weeks]

So at week 4 you had a 2 log drop or better, but were not considered undetectable correct? Did you ever make it to undetectable and if so do you know what your vl was when you did(what week) and did you achieve svr yet? I looked at your profile, but couldn't tell if you did or not.

At this point I'm pretty upset with my gastro because the test he gave me 3 times for my pcr was the NGI HCV SuperQuant it only says Less than 40 IU/mL. I feel like all this time he was saying I was undetected, but I wasn't necessarily and I'm in week 40. Didn't mean to hijack this post.

[pooh55811]

Yes, they use the test result at specific intervals to determine if you are responding to treatment and if you can continue treatment. (Futility Rules)

They also use the test to determine how long you do treatment.

As an example, I was on Interferon, Ribavirin, and Incivek. At week 4,  I had to be under 1000 in order to even continue treatment (Futility Rule). I also had to be Undetectable to be considered eligible to do 24 weeks of treatment. I was under 1000 at week 4, but I was <43 Detectable at week 4, so I had to do 48 weeks of treatment.

[gopkrs]

Haven't they also been using that in the sense that even though it is detectable; it is low enough that we want you to continue Tx??

[Bali05]

You can also ask for a sensitive Qualitative PCR instead of the Quantifiable PCR. The Qual.
will only result in deteteced or not detected.
Since you are already below 40 for sure , all you really need is a Qual.
The Qualitative PCR according to my hepatologist tend to be somewhat
more sensitive anyway because they just need to detect not count.

b

[gsx1250fa]

From what i understand...the test result is either detectable...or undectable. My first and second week blood draw were <25 detectable. The machine couldn't give a definite number  from 1 to 25 or maybe 1-24...but still was detectable. Week 4 is when I became officially UND. Nonetheless I (we) are pulling for you :)

[pooh55811]

"my guess is what they mean is that when the VL gets that low...there is a "good" chance of killing it within the parameters of previous studies.
------------------------------------
No, what they mean is that the test cannot count the virus if the virus is less than 40 IU/mL. If the viral count is 39 IU/mL, that test is going to come back  as less than 40 IU/mL because the test cannot count the virus particles if there are less than 40 IU/mL. If you did a test that was able to count lower, lets say a test that counted as low as 25, then if your viral count is 39 IU/mL the test would be able to count it and the test would say your result was 39 IU/mL.

What I am getting at is that the test is accurate, the count is below 40, but that does not tell you if the virus is Undetectable. Maybe with a more sensitive test the virus would be detectable because the more sensitive test would be able to count lower.

The other thing is the test should state if the virus is Detected or Undetected. Even if the test cannot count below 40, it can usually detect lower than 40, perhaps down to 10 or 15. So a test could say:

Less than 40 IU/mL ,    Detectable
or it could say:
Less than 40 IU/mL ,    Undetectable

But you need to know if it was DET or UND.


Or are they saying that with that low of a VL; maybe the test was inaccurate?  Anyone know for sure?? "
----------------------------------
They are not saying it is inaccurate. They are saying the test can count only as low as 40. Anything lower and the test cannot count it. However, most tests can detect lower than the number to which they count, which is why you need it to say DET or UND.

[pooh55811]

"3 pcrs including the most recent one have brought back "Less than 40 IU/mL" which my Dr. says is what we want. He says that's considered undetectable. "
-----------------------------

A agree with the above posters, Bali and Can-do-man, that "Less than 40 IU/mL" means exactly what it says, that the HCV RNA level/count is less than 40 (below the lower limit of quantification). That test should also indicate whether it is Detectable or Undetectable. A person can have a test result of less than 40 IU/mL and still be Detectable so you need to be sure that the test actually says Undetectable.

[can-do-man]

""Less than 40 IU/mL" which my Dr. says is what we want. He says that's considered undetectable."

Might want to show your doctor this from the Mayo Clinic

A "Detected" result with the comment "HCV RNA level is <43 IU/mL (<1.63 log IU/mL). This assay cannot accurately quantify HCV RNA below this level" indicates that the HCV RNA level is below the lower limit of quantification for this assay. When clinically indicated, follow-up testing by this assay is recommended in 1 to 2 months. For the purposes of assessing response-guided therapy eligibility, an "Undetected" result is required; a "Detected" result below the limit of quantification should not be considered equivalent to an "Undetected" result.

http://www.mayomedicallaboratories.com/test-catalog/Clinical+and+Interpretive/83142

[gopkrs]

I don't know but my guess is what they mean is that when the VL gets that low...there is a "good" chance of killing it within the parameters of previous studies. Or are they saying that with that low of a VL; maybe the test was inaccurate?  Anyone know for sure??

[Bali05]

""Less than 40 IU/mL" which my Dr. says is what we want. He says that's considered undetectable."

That would imply that a viral load of 20 IU is considered UND but that simply
is not the case. A friend of mine unfortunately never cleared the virus his
viral load stalled at around 2-5 IU  by wk24.Your Dr. would have called this UND and have him needlessly do the entire course of tx.
Just saying it is rare but it happens. For me only the most sensitive
PCR I can get my hands on will do. This is either the Labcorp NGI QuantSure
<2 IU  or the Quest Diag. TMA < 5IU.
Chances are you will be UND with a more sensitive test but I would want
to know for sure.

b

[gsx1250fa]

Hi. I am not a doctor, but have read about Alt and Ast increasing while on Tx...probably or possibly due to the interferon. I don't know if this is correct or not, but some more knowledgeable folks here might chime in. Good luck :)

[48weeks]

Hello - I am approaching my 9th month of 48 week triple therapy, now w/just the Ribiviran and Interon. I am a stage F1-F2. 3 pcrs including the most recent one have brought back "Less than 40 IU/mL" which my Dr. says is what we want. He says that's considered undetectable. I also get other lab work done every 6 weeks. My last several lab results show liver enzymes are alt (sgpt) 144 ast (sgot) 114 when before treatment they were around 75 to 80. My gastro says this may be due to fatty liver yet he has not sent me in for any imaging to confirm. So I feel your pain. Part of me wants to take some of my lab results to a hepatologist to see if he/she would suggest doing anything different, the other part says I have 8 weeks and I need to be more patient.

[gsx1250fa]

Thanks. I am going on vacation here shortly for a week and will get my blood checked when I get back.

[Bali05]

The easiest way to find out is to stop heavy weightlifting for a week or
two and check enzymes again. We are all different but from what I know
it is mostly AST that gets elevated from muscle not so much ALT.
ALT is more liver specific than AST.
I do a lot of cardio and some resitance training but never have elevations
this high. Also when your body is used to training you should not
see elevations this high in my opinion unless you take peformance
enhancing drugs. To give you an idea I can hit my exercise bike (spinning)
for an hour , be drenched in sweat and do some weight lifting afterwards
and all I will see is my AST come up a few points but still way in the
normal zone.


b

[gsx1250fa]

Thanks. I will try that. Apparently the tear down rebuild of muscle tissue releases these enzymes also. Never knew this :)

[jules2551]

Don't exercise before you do the labs.  It will really elevate those numbers.  You can work out afterwards.  

[gsx1250fa]

Thanks. I will check into that with my Doctor. You are correct about the elevation correlated with weight training. They call it a somewhat "False" positive reading. My training is somewhat intense 4 sometimes 5 days a week with heavy squats, deadlifts etc. thks

[jules2551]

You might want to have your Dr run a CPK and CK-MB blood tests.  These tests can help diagnose muscle damage from say weight lifting, heart attack, or stroke.  If you are exercising that much these tests will be elevated and yes it will elevate your ALT/AST numbers.

Good luck!

[gsx1250fa]

Interesting. I have been weight training pretty heavily for the last year and just read a couple of articles that Heavy Exercise/weight lifting can cause elevated Alt and Ast scores.

[Bali05]

In some people the meds themselves can cause elevated enzymes.
My liver enzymes @ EOT were as high as when I started
but immediately dropped to low 20s only a couple of wks after tx.
When you are UND and still have elevated enzymes the cause
is likely to be something other than the virus.

b

[gsx1250fa]

Thanks. Unfortunately I don't get to talk to the actual Doctor in charge of the whole deal very often and the last time was at the beginning of the study. I was actually referring to the doctor's assistant. My levels have been through the roof for years. Maybe the reason I have gone from stage 2 to stage 5 in 3 years. The docs assistant seems to think my liver has a chance at somewhat repairing itself over time if I am able to reach SVR. I am not sure if elevated enzymes means continuing liver damage...or just part of the process. thks

[gopkrs]

That is definitely a question for the doctor. He sounds like he talks to you so why not get him to answer the question? I have been undetected for 5 months on triple therapy and my ALT and ASTs are in normal range...whatever that signifies. But don't think I was ever as high as you at the start. Sounds like a good thing that you have come down so much.