From the Guidelines
For a 73-year-old female with elevated liver enzymes (AST 92, ALT 102), low albumin (3.2), normal anion gap (-11), and low A/G ratio (0.8), I strongly recommend ordering a complete hepatitis panel, including HAV-IgM, HBsAg, and Hepatitis B core antibody-IgM fraction (HBcIgM), HCV antibody, and consider HCV-RNA, as suggested by the American Gastroenterological Association medical position statement 1. The patient's laboratory results indicate hepatocellular injury, and the low albumin level suggests some synthetic dysfunction.
- Key tests to consider include:
- Complete hepatitis panel
- Liver ultrasound
- Complete blood count
- Comprehensive metabolic panel
- Prothrombin time/INR
- Gamma-glutamyl transferase (GGT)
- Testing for autoimmune hepatitis with ANA, anti-smooth muscle antibody, and immunoglobulin levels
- Evaluation for non-alcoholic fatty liver disease, alcoholic liver disease, and medication-induced liver injury The low A/G ratio indicates relatively higher globulin levels compared to albumin, which can occur in chronic liver disease or inflammatory conditions, as noted in the guidelines for evaluating patients with evidence of hyperbilirubinemia and cholestasis 1. A thorough medication review and alcohol history are essential to determine the underlying cause of the liver enzyme elevations. If initial testing is inconclusive, consider referral to a gastroenterologist for possible liver biopsy, especially if chronic HCV viremia is suspected, as recommended by the guidelines 1.
From the Research
Laboratory Results Interpretation
The patient's laboratory results show elevated AST (92) and ALT (102) levels, indicating hepatocellular injury. The albumin level is 3.2, which is slightly below the normal range. The anion gap is -11, and the a/g ratio is 0.8.
Further Testing Recommendations
Based on the patient's laboratory results, the following tests are recommended:
- Testing for liver-related autoantibodies to diagnose autoimmune hepatitis (AIH) and primary biliary cholangitis (PBC) 2
- Viral hepatitis panel to rule out hepatitis A, B, and C 3
- Assessment for nonalcoholic fatty liver disease and alcoholic liver disease 3
- Screening for hereditary hemochromatosis, Wilson's disease, and alpha-1 antitrypsin deficiency 3
- Complete blood count to evaluate for cytopenias, which can be a complication of autoimmune liver diseases 4
- Imaging studies, such as ultrasound or MRI, to evaluate liver morphology and rule out biliary obstruction 3
Potential Causes of Elevated Liver Enzymes
The patient's elevated AST and ALT levels can be caused by various factors, including: