What is the diagnosis for a patient with hyperglycemia, normal Blood Urea Nitrogen (BUN) levels, impaired renal function indicated by low creatinine levels, elevated estimated Glomerular Filtration Rate (eGFR), normal BUN/Creatinine ratio, hyponatremia, hypokalemia, hypochloremia, normal carbon dioxide levels, hypercalcemia, normal protein levels, hypoalbuminemia, normal globulin levels, hyperbilirubinemia, elevated alkaline phosphatase, elevated Aspartate Aminotransferase (AST), and normal Alanine Aminotransferase (ALT) levels?

From the Guidelines

The patient's lab results indicate liver dysfunction, and given the persistent enzyme elevations and improving bilirubin levels, a thorough evaluation for causes of liver dysfunction such as medication effects, alcohol use, viral hepatitis, or biliary obstruction is warranted, as suggested by the American Gastroenterological Association 1. The patient has consistently elevated blood glucose (123,100,114 mg/dL) above the normal range of 70-99 mg/dL, indicating hyperglycemia. Liver function tests reveal elevated total bilirubin (3.0,2.5 mg/dL) that improved to near normal (1.1 mg/dL) in the most recent test. Alkaline phosphatase remains persistently elevated (130-133 IU/L), as does AST (62,48,44 IU/L), while ALT is within normal range. Some key points to consider in the evaluation of this patient include:

• The patient's AST and ALT levels, which are indicative of liver cell injury, with AST being elevated and ALT being within normal range, suggesting a possible cholestatic pattern of liver injury.
• The elevated alkaline phosphatase levels, which can be seen in cholestatic liver disease, as well as in bone disorders.
• The patient's bilirubin levels, which have improved over time, but were initially elevated, suggesting a possible hepatic or biliary obstruction cause.
• The patient's electrolyte abnormalities, including low sodium, potassium, and chloride levels, which have improved over time, but may still require monitoring and management.
• The patient's recent hypercalcemia, which may require further evaluation and management. Given the complexity of the patient's presentation, a comprehensive evaluation, including a thorough history, physical examination, and laboratory testing, is necessary to determine the underlying cause of the liver dysfunction and to guide management, as recommended by the Mayo Clinic Proceedings 1. Additionally, the patient's kidney function, as indicated by the eGFR values, appears to be normal, but the low creatinine levels may require further evaluation, as suggested by the Journal of Hepatology 1. Overall, a thorough and multidisciplinary approach is necessary to evaluate and manage this patient's liver dysfunction, and to address the associated electrolyte and metabolic abnormalities.

From the Research

Laboratory Results

• The patient's laboratory results show elevated levels of AST (SGOT) at 62 IU/L, 48 IU/L, and 44 IU/L, which are above the normal range of 0-40 IU/L 2, 3.
• The patient's ALT (SGPT) levels are within the normal range at 37 IU/L, but the AST levels are elevated, indicating potential hepatocellular injury 3.
• The alkaline phosphatase levels are elevated at 130 IU/L, 133 IU/L, and 132 IU/L, which are above the normal range of 44-121 IU/L, indicating potential cholestatic injury 3, 4.
• The total bilirubin levels are elevated at 3.0 mg/dL, 2.5 mg/dL, and 1.1 mg/dL, which are above the normal range of 0.0-1.2 mg/dL, indicating potential liver dysfunction 2, 3.

Electrolyte and Acid-Base Disturbances

• The patient's sodium levels are low at 131 mmol/L, but then return to normal at 142 mmol/L, indicating potential hyponatremia 5.
• The patient's potassium levels are low at 3.2 mmol/L and 3.4 mmol/L, but then return to normal at 4.6 mmol/L, indicating potential hypokalemia 5.
• The patient's chloride levels are low at 90 mmol/L, but then return to normal at 105 mmol/L and 102 mmol/L, indicating potential hypochloremia 5.

Liver Disease Evaluation

• The patient's liver test results indicate potential liver disease, and further evaluation is necessary to determine the etiology 6, 3, 4.
• The patient's medical and family history, substance use, and medication use should be reviewed to identify potential causes of liver disease 6, 3.
• Additional tests, such as hepatitis B and C antibodies, ferritin and iron levels, and right upper quadrant abdominal ultrasonography, may be necessary to evaluate the patient's liver disease 6, 3.