What is the significance of elevated alkaline phosphosphate (alk phos) levels, slightly elevated aspartate transaminase (AST) and alanine transaminase (ALT)?

From the Guidelines

Elevated alkaline phosphatase (ALP) with slightly elevated AST and ALT suggests liver dysfunction that requires medical evaluation, with a possible cholestatic process rather than primarily hepatocellular injury, as indicated by the pattern of elevation 1. These liver enzymes typically indicate inflammation or damage to liver cells, with ALP specifically pointing to possible bile duct issues. The severity of abnormal aminotransferase can be classified as mild, moderate, or severe, and in this case, the slightly elevated AST and ALT suggest a mild elevation 1.

Key Considerations

• The patient should schedule an appointment with their healthcare provider for further testing, which may include a comprehensive metabolic panel, hepatitis screening, and imaging studies like ultrasound or CT scan 1.
• Avoidance of alcohol, acetaminophen, and potentially hepatotoxic medications is recommended until the patient has been evaluated 1.
• Common causes of elevated liver enzymes include fatty liver disease, viral hepatitis, medication side effects, alcohol use, autoimmune conditions, or biliary obstruction 1.
• The pattern of elevation (ALP being more prominently elevated than the transaminases) suggests a possible cholestatic process, which may require imaging of the biliary tree to determine the etiology of extrahepatic or intrahepatic cholestasis 1.

Next Steps

• The patient's doctor may recommend lifestyle modifications, including weight loss if appropriate, dietary changes, and treating any underlying conditions 1.
• The severity of elevation and the patient's symptoms will guide the urgency of evaluation and specific treatment approach 1.
• Measurements of GGT can indicate whether pathologically elevated ALP is of hepatic or nonhepatic origin, and concomitantly elevated GGT can help confirm that an elevated ALP originates from the liver and indicates cholestasis 1.

From the Research

Significance of Elevated Alkaline Phosphatase (ALP) and Transaminase Levels

• Elevated serum levels of transaminases (AST and ALT) usually indicate hepatocellular damage, while ALT elevations can also be of extrahepatic origin (muscle) 2
• Elevated ALP levels can be associated with various conditions, including liver disease, bone disease, and malignancy 3
• An isolated elevated ALP level of unclear etiology is associated with several specific and important disorders, including metastatic intrahepatic malignancy, and is uncommonly associated with primary parenchymal liver disease 3

Clinical Interpretation of Laboratory Results

• Hepatocellular injury is defined as disproportionate elevation of AST and ALT levels compared with ALP levels, while cholestatic injury is defined as disproportionate elevation of ALP level as compared with AST and ALT levels 4
• The degree of elevation of ALT and/or AST in the clinical setting helps guide the evaluation, and a true healthy normal ALT level ranges from 29 to 33 IU/l for males and 19 to 25 IU/l for females 4
• Elevated ALP levels may help identify high-risk symptomatic hemorrhagic transformation in ischemic stroke patients with atrial fibrillation and/or rheumatic heart disease 5

Potential Causes of Elevated ALP and Transaminase Levels

• The most common causes of ALP elevation include underlying malignancy, bone disease, and unsuspected parenchymal liver disease 3
• Elevated transaminase levels can be caused by various factors, including viral hepatitis, nonalcoholic fatty liver disease, alcoholic liver disease, and drug-induced liver disease 2, 4
• Hyperthyroidism can also be associated with abnormal biochemical tests, particularly ALP elevation, and may pose diagnostic confusion 6