Your AST/ALT levels post tx

[hepCC]

Hi all,
I am interested in how your AST/ALT levels were in the first months post tx. Did they rise or go down? Did you relapse or go on to SVR?

The reason I ask is that my ALT has been slowly climbing in the six weeks since tx. According to my nurse this is normal. I cannot find any support for her statement anywhere, on the contrary it looks to me as if the ones who svr go down post tx and stay there. I'd prefer to know where I stand in case nurse is trying to soften bad news.

CC

[zazza]

I think a clarification is needed that we need to distinguish between "healthy" and "normal" range of liver enzymes. What we want is a healthy liver not a normal liver, since a lot of people in a normal population group do not have healthy livers. One reason might for example be excessive alcohol consumtion. So "healthy" ALT for someone with a BMI < 25, would be an upper limit of 19 for women and 30 for men according to this Italian study.

[zazza]

If I had been obese, the doctors would have been correct in saying that my liver enzymes were normal. :)

[zazza]

Interestingly enough, on the video sometimes referred to on this forum, with Dr Dietrich, he uses exactly the same upper limit of normal liver enzymes as in the Italian study, ie:

19 for women,
30 for men

Mikesimon, I also had "normal" liver enzymes before tx, but was always told by the doctors that this was not a guarantee against cirrhosis and fibrosis. All though not as many with "normal" liver enzymes as with elevated enzymes get cirrhosis, still some do. One more reason to get a biopsy, even if I could not because of clotting issues.

My ALT was before tx, between 1995 and 2006, never below 19 (except once when I was pregnant when liver enzymes apparently normalize). Post tx my ALT has been between 9 and 14. So much for my liver enzymes being normal before. My BMI is almost exactly 25.

[jmjm530]

Thanks. Yes, "skinny" seems to be healthier although at least in this culture skinny people are often looked at as less healthy than those with a low but more normal BMI.

[mikesimon]

I have seen many studies equating low weight with longer longevity. I mean skinny and not what we consider normal or healthy. I have also seen animal studies which support this relationship - mice comes to mind.

"School of Medicine and Pharmacology, Fremantle Hospital Campus, The University of Western Australia, Fremantle, Australia.

Background and Aims: The relative effects of obesity compared to alcohol on liver injury are uncertain. We examined their effects on alanine aminotransferase (ALT) and gamma glutamyltransferase (GGT) levels in a population-based cohort. Methods: Adult residents (2610: 1326 males, 1284 females) from Busselton, Australia, participated in a cross-sectional survey determining alcohol intake as determined by a validated questionnaire, anthropometric measurements and serum analysis. Alcohol consumption was classified as never, light (420 g/week). Results: The majority of subjects were either overweight (41%) or obese (17%). A minority of subjects were moderate (25%) or heavy drinkers (4%). Body mass index (BMI) and waist circumference were strongly associated with ALT and GGT (P < 0.0001 for all tests). Alcohol consumption was modestly associated with ALT in females (P = 0.01) but not in males (P = 0.9). In contrast, GGT was significantly associated with alcohol in both genders (P  0.2 for all tests). Conclusions: Excess weight is more common than excessive alcohol consumption in the community and confers a greater risk of elevated aminotransaminase levels."

"Relation between body mass index and serum aminotransferases concentrations in professional athletes.
Banfi G, Morelli P.

IRCCS Galeazzi, Milan, Italy. ***@****

AIM: Reference intervals commonly used for evaluating and interpreting laboratory values obtained in athletes are the same used in the general population. Aminotransferases (aspartate aminotransferase [AST], and alanine aminotransferase [ALT]) are commonly analyzed in serum for evaluating hepatic function. Some studies in the general population and in blood donors testified that ALT concentrations clearly correlated with weight and body mass. METHODS: We compared the aminotransferase concentrations at rest of 116 male professional athletes of 7 different sport disciplines with their body mass index (BMI). The blood drawing was performed before the start of training and of the competitive season. The athletes engaged in rugby, triathlon, soccer, sailing, cycling, basketball, alpine skiing. One hundred age-matched, apparently healthy, not physically active, males chosen for general check-up were recruited as a control group. RESULTS: The average concentrations of AST and ALT in the whole group of athletes were 24.4 U/L (standard deviation [SD]: 10.5) and 23.6 (SD: 6.5). The results in athletes were not statistically different from those of sedentary people. A positive correlation between BMI and ALT exists, whilst a very weak negative correlation between BMI and AST occurs. CONCLUSION: High concentrations of ALT should be evaluated considering BMI values whilst high values of AST should be evaluated considering the influence of physical exercise."

See:  http://www.ncbi.nlm.nih.gov/sites/entrez

Mike

[jmjm530]

If either of you still have links to studies not posted here regarding the relationships between BMI (athletes or not) , Stetotosis, and ALTs, I'd appreciate if you post them.

BMI keeps coming up more and more regarding liver health and even treatment outcomes. Don't know if anyone caught the new studies on runners living longer. The difference was DRAMATIC and I wonder how much a lower BMI (I'm making an assumption here) or even different diet/healthstyle habits might have played into the equation as opposed to the actual exercise.

[jmjm530]

Holy Moly Good God it's the end of the world - Mike and Jim agree!!!!!!!!!!!!!!!!!!!!!
-----------------------------------------------------
I guess you don't remember all our little "discussions" on one very sensitive subject here, yet we still agree on most things. My guess is that Mike and myself agree most of the time although the differences might make better reading :)

[mikesimon]

I saw the reference to steatosis and pretty much surmised the same thing - although I didn't think it was very clear. It also seemed to me that lowering the normal range might have had more to do with some threshold screening for viral infection than it did with determining a "healthy" normal range but again, I didn't think it was clear. Then I went to PubMed related articles and saw ALT related to BMI in athletes. Basically this is a topic I haven't spent any time studying and I am not likely to study it any further now.  
Mike

[redrodeo]

     I don't know what nygirl7 meant but I understand you going over and over it in your head.The tests aren't that expensive. After 6 weeks you really don't need a supersensitive test.By now if you have relapsed it will show up.
     You situation is very similiar to mine. I did 24 wks for geno 3a and finished May 11. So I have had two general blood tests and this monday we did the 3 month check up which includes vl. I am nervous myself. The first two tests the ALT remained below 20.
AST was a little above 20 but stable. My doctor was very enthusastic. In the past my ALTs were already up to 40 or so and I knew I had relapsed. So this time I don't know.I was RVR and undet at 3 1/2wks. Theres nothing more I can do now just wait for the results which may be in by Fri or early next week. I am just so tired of messing with this thing, I want it to be over.
      But if I were you I'd be concerned also.
      Red

[CockSparrow]

The relationship between BMI and ALTs probably has to do with Steatosis.

HepCC
There is a difference between normal range and a healthy liver.
Anything above 30 is suspect whith HepC.
The normal range has a 5% margin of error.
What this means is that 95% of people in the normal range will have nothing wrong with them. The reason why normal ranges are different is that its a stat used and kept by each lab. And therefore can be different between labs.

CS

[nygirl7]

Holy Moly Good God it's the end of the world - Mike and Jim agree!!!!!!!!!!!!!!!!!!!!!

Let me go get that winning lotto ticket, quickly!!!!!!!!!!!!!!!!

;)

Sorry dudes couldn't help it it just slipped out!  :)

[mikesimon]

I, like Jim, found the cited article less than crystal clear. I did go to the related PubMed articles and there does seem to be some type of correlation between BMI and ALT but I can't draw any relevant conclusions from what I read. Previous to this discussion I have seen some persuasive arguments in articles which advocate implementing a lower normal range for ALT. I cannot speculate as to why your ALT was not far out of range and yet your liver was damaged like it apparently has been.

Mike

[jmjm530]

Come to think of it, my BMI was also reduced on a higher fat "Zone" type of diet, but my ALT's did not normalize. So much for that :)

[jmjm530]

The study cited was presented/translated badly, at least that is my take. That said, if what it said was that the upper limit of "normal" ALT levels are really too high -- then this supports other similar (but better written :) ) studies. Personally, my ALT sometimes fell within "normal" range (just under the upper limit) prior to treatment, however once SVR it dropped into the teens. I'm sure I have company here in that. The other interesting point regards BMI and ALT. Still a bit  unclear from the study, but if it suggests lower BMI equals lower ALT, it also hits a personal note because the times my ALT (prior to tx) fell into normal range I was on a very low fat diet. I assumed it was the diet, but indeed it may have been the weight loss, although this is really speculation.

[hepCC]

"The body weight relationship is news to me. I don't recall ever hearing about ALT normal range relating to body weight so I cannot comment on that issue."

zazza on this forum told me about an Italian study on this subject. I found the abstract here:
http://annals.highwire.org/cgi/content/abstract/137/1/1

This was very interesting to me. In Sweden what is considered healthy range is 45u/l for women and 66u/l for men, If I have calculated correctly. I have been in the healthy range and sometimes just slightly above and still developed bridging fibrosis. Could be that for me the healthy range was far to high, and my enzymes have actually been elevated all along. My BMI has always been in the range of 17-20 as an adult. Not doing the analysis based on the individual, but a general "healthy range" could explain why such a big percentage of HCV infected have "normal liver enzymes".

CC

CC

[hepCC]

How I wish I could do that! Health care works different here, and I am to wait six months for a pcr, no matter how it looks. I will try to get one a little earlier, but it's not likely I'll succeed.

CC

[jmjm530]

There's no reason for you to guess what's going on. Simply ask your doctor for a sesitive viral load test. At six weeks post treatment, an UND should correlate around 90% with SVR.

[hepCC]

OK! I know I worry a lot. But we do so much want to get our health back, don't we!

I felt much better after your replies and went out to walk the dog. Very relaxing :)

CC

[pigeonca]

After tx my ALT was down to 19.  Since then it has varied all over the place, ranging from 19 to 29.  As long as it's within normal range, I believe there is quite a bit of variability but nothing to worry about.

[mikesimon]

Those numbers really don't look bad - they look really good to me. You had almost no increase in AST and your ALT increase was rather modest. The body weight relationship is news to me. I don't recall ever hearing about ALT normal range relating to body weight so I cannot comment on that issue. I think that if I were you I would be able to relax and relaxation doesn't come easy to me. Of course I know that any increase in ALT can cause concern but considering how small your increase is I wouldn't worry too much about it. You could very well see it drop on your next labs. The fatigue is not an indicator in my opinion. It takes a while before you feel close to normal and I just don't believe that is an indication of relapse. I can tell you that I relapsed within 2.5 weeks and my enzymes were a lot higher than yours are at 6 weeks post and I didn't notice anything that led me to believe I had relapsed. Some people claim they knew and a lot of others really didn't have a clue so I wouldn't get consumed with worry that you're still suffering from fatigue. The bottom line is, at this point we don't know. I don't know what the rules are in Sweden but if you're really worried about this and can get tested that's what I would do. My opinion is that if you are undetectable at 6 weeks post the odds are really in your favor for achieving SVR. But, most people can't get tested so that may not be a possibility for you.
Again, I wish you luck CC.
Mike

[hepCC]

Thank you for your answers and support!

My enzymes went down steadily all through tx and became excellent. I did only 24 weeks (geno 3a)

After shot 18 my ALT was 15.6, and AST 23,4. I didn't have any more tests during tx.

Eight days post tx ALT 19,2 AST 24

Six weeks post tx ALT 25,2 AST 24

I know well that these are not bad numbers, but also want to mention that I am very thin. From what I understand body weight should be taken into consideration when deciding normal levels for liver enzymes. At end of tx I had a BMI of 14.5 and at six weeks post it was 15.2

What worries me most is the trend I see here! I also have the same fatigue as pre tx.

CC

[nygirl7]

mine stayed under 20 and I've been SVR for 18 or 19 months now.

However, I remember when they bounced around from 25 to like 35 during treatment I insisted on having an EMERGENCY appointment with my doctor and drove so fast I should have crashed.  He laughed at me - literally and told me to get a grip on myself that it was no big deal whatsoever and meant nothing.

Hoping your 'rise' is just like that - small and meaning nothing.  

I wish you the best of luck too!

[mikesimon]

I think we'd all like our enzymes to decrease to well within normal range and stay that way so I understand your anxiety. Unless your enzymes are significantly elevated I would try not to get too upset about it. I'm not sure that I would necessarily agree with your nurse that it's normal to see an increase in enzymes after stopping but it certainly isn't unheard of and I have seen members here report elevated enzymes at the end of treatment and yet still go on to achieve SVR.  I think you just have to try not to read too much into it at this point but I know that's a lot easier said than done. I am curious to know your enzyme numbers since you stopped TX. I do wish you the very best luck - SVR. Mike