Elevated ALT, AST and ALP- acute renal failure?

[careerchg09]

Hi- Trying to connect the dots...I'm a nursing student working on a case study. I'm stumped on the elevated ALT, AST and ALP and whether they can be related to the patient's acute renal failure or whether its indicative of another otherwise unknown liver disease process.

Values:

ALT 377 (Norm 30-65),

AST 128 (norm 8-42)

ALP 136 (norm 37-107)

Other possible relevant data: 94 y/o, admitted for pneumonia, hx of COPD, CHF, A fib, BPH, yada yada yada.

Thanks much!

[Whispera, MSN, RN]

check into liver dysfunction and alcohol abuse....

[careerchg09]

No history of liver disease and/or alcohol abuse noted in the chart. Not likely associated with renal failure then, huh?

Thanks for the thought.

[Whispera, MSN, RN]

Keep in mind that sometimes people don't tell anyone they drink. They may think they don't drink much. Having elevated liver enzymes is one big sign of long time alcohol abuse, however. They indicate the person should be watched for signs of withdrawal if in the hospital for more than a few days, even if they haven't said they drink.

[highlandlass1592, BSN, RN]

Should also consider right heart failure..could lead to hepatic congestion. Don't think you can tie the liver studies into ARF, you're talking two totally different systems.

[Virgo_RN, BSN, RN]

What type of heart failure do they have? Any Hepatitis panels done?

[Whispera, MSN, RN]

all of the above....I agree....

[careerchg09]

Thanks for the thoughts on the alcohol intake. Patient was also on vent secondary to the respiratory failure upon admission, so there was no "taking a history".

The heart failure was not specified in the documentation. Although, I can see the link from the right sided failure to hepatic congestion. Would that be considered hepatic portal hypertension? Or is that taking it too far?

No hepatitis panels done that I am aware of. The focus appeared to be on the a. fib, an amiodarone infiltration causing cyanosis and necrosis of the hand and the acute renal failure. The liver enzymes weren't a priority it seemed.

Taking this in a completely different direction: I can't help but wonder whether the pneumonia was in fact masking amiodarone lung toxicity.

[WalkieTalkie, RN]

Amiodarone itself can cause hepatotoxicity...

[snicuradrn]

Look into hepato-renal syndrome, generally caused by liver cirrohosis. Has there been any lab testing for copper levels indicative of Wilsons disease, also look into mitochondrial DNA testing and ANA results to name a few these few blood tests will point the way with respect to the liver. Advanced testing can determine if it is an autoimmune disease ie Wilsons or an acute hepatitis causing ARF. By the way, being in Afib for an undetermined amount of time can itself be the cause of both elevated LFT's and ARF. As with most new onset afib patients, they decrease blood pressure which in turn decreases blood flow to non vital organs such as kidneys and liver. The liver can go into shock, and kidney failure can occur in just 10 minutes of hypotension or if the patient typically runs hi a drop that sometimes occurs with the initiation of amio. Alcoholics generally have lower than normal magnesium levels. There are many possibilities with this case as at least 4 systems are affected. Awesome learning experience. more info and testing is required though.

[core0]

Some good suggestions here. I would not favor alcohol for two reasons. The AST/ALT ratio is the wrong way. In alcohol AST>ALT is the norm. AST/ALT ratio greater than 2 is almost diagnostic for acute alcoholic hepatitis. Alkphos is also very senstive to ETOH (although GGT is a better test). With a fairly normal Alkphos its unlikely to be ETOH (also Alkphos is elevated in renal failure). Cirrhosis also generally has a AST>ALT ratio. Most other liver diseases have an ALT>AST ratio.

Another issue is timing. What were the baseline LFTs? Have they gone up after iniating any new therapies or are have they been elevated all along. Are they going up or down. Once the liver starts to recover, the AST will generally drop before (and faster) than the ALT.

To really evaluate liver function you need at least one more test. The INR will tell you a lot about hepatic function. Its the most sensitive test for failure.

My differential would be

Med

Right heart failure (the etiology here is outflow obstruction with central venous hepatocyte congestion).

Viral hepatitis

The differentiation will be between the timing of meds and the rise in LFTs.

Just to make things more confusing heart failure can cause renal failure or renal failure can cause right heart failure (through volume overload). So yes this could all be renal failure.

David Carpenter, PA-C

[silas2642]

His elevated LFT's may definitely not be d/t an alcohol insult; oftentimes with alcoholic liver injury the AST/ALT ratio is going to be elevated whereas in other actue liver injury the AST/ALT is lower-- that is, ALT>AST. He is old, and a lot of old people are on a lot of medications, he is in acute renal failure, which means his body isn't clearing medications very well. I would think drug toxicity before I would think anything else. I have no idea what medications he is on, but amiodarone isn't the worse place to start, as another person mentioned. When you hear hoofbeats, think horses, not zebras.