Elevated ALT, AST and ALP- acute renal failure?

Magsulfate, BSN, RN · Apr 2, 2009

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.

I second this. :)

Magsulfate, BSN, RN · Apr 2, 2009

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.

I agree with this too.

Try not to read something into it that is not there. This is nursing school after all, not medical school.

Magsulfate, BSN, RN · Apr 2, 2009

Thanks for posting this... this is very interesting, I learned something new. :)

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

careerchg09 · Apr 3, 2009

Thanks all for your ideas and thoughtful responses. I've really absorbed a lot on this one.

Magsulfate, you are correct- its just nursing school- lol. Point well made.

David, INR was 1.2. This is a relatively low value, but wouldn't it be affected by the heparin drip administered for the a fib (and to help reperfuse the cyanotic right hand from the infiltration)? Also, fyi, PT was 12 and PTT 71- again I've attributed those elevated values to the heparin. No?

Also, I'm confused on the right sided failure resulting from fluid overload. With fluid overload, I would have suspected left sided failure because the left ventrile is unable to overcome the systemic vasular resistance associated with the excessive fluid. In right sided failure, any excessive fluid would be caused by resistance in the pulmonary vasculature, no? I think I may be missing something here.

core0 · Apr 3, 2009

Thanks all for your ideas and thoughtful responses. I've really absorbed a lot on this one.
Magsulfate, you are correct- its just nursing school- lol. Point well made.
David, INR was 1.2. This is a relatively low value, but wouldn't it be affected by the heparin drip administered for the a fib (and to help reperfuse the cyanotic right hand from the infiltration)? Also, fyi, PT was 12 and PTT 71- again I've attributed those elevated values to the heparin. No?
Also, I'm confused on the right sided failure resulting from fluid overload. With fluid overload, I would have suspected left sided failure because the left ventrile is unable to overcome the systemic vasular resistance associated with the excessive fluid. In right sided failure, any excessive fluid would be caused by resistance in the pulmonary vasculature, no? I think I may be missing something here.

Two different processes. I didn't explain it well. Fluid overload usually causes left heart failure. ARF can put you in this bad cycle where you get fluid overload then get low oxygen to the kidney which leads to more ARF which leads to more fluid overload etc.

Liver dysfunction with heart failure is usually caused by right heart failure. In this process there is passive venous congestion. This leads to central lobular congestion and elevated LFTs. The right heart failure can be from Cor-pulmonale or pulmonary hypertension (also from MI). Severe left heart failure can cause right heart failure (what is the most common cause of right heart failure on our boards). Another place you see this is in Hepatopulmonary syndrome. This is essentially pulmonary hypertension in the setting of cirrhosis. In this case you have increased LFTs from cirrhosis and from the right heart failure. Its a hard picture to tease out since cirrhotics usually won't mount much of an LFT response unless they get thrown over into frank failure.

You can also get liver failure from hypotension from left heart failure but the liver is more resilent than the kidney. When you do get it, its in the setting of "shock liver" where the LFTs are in the high hundreds to 1000's.

As far as INR its hard to tell if the 1.2 is significant or not. In the setting of someone that is sick I would suspect not. If it was around 2 then thats a different story.

The other issue is that almost anybody thats sick can have mildly (

David Carpenter, PA-C

careerchg09 · Apr 3, 2009

Thanks much for your detailed explanation. That really helps to clear it up in my mind. I can see your point about the overlooked labs.

I'm grateful for the help in understanding these complex processes and so impressed with the wealth of knowledge people are willing to share.

I'm grateful to have stumbled onto this site.

kanzi monkey · Apr 3, 2009

check into liver dysfunction and alcohol abuse....

AST is usually higher than ALT w/ alcohol abuse or drug toxicity.

kanzi monkey · Apr 3, 2009

Ohh, so many great replies that, ummm, already covered what I just said. Sorry.

Great discussion!

-Kan