From the Guidelines
Multiple myeloma can indeed cause elevations in alkaline phosphatase and transaminases, although this is not a typical presentation of the disease. Liver involvement in multiple myeloma usually occurs in advanced stages and may manifest as hepatomegaly with mild to moderate elevations in liver enzymes 1. Alkaline phosphatase elevations are more commonly associated with significant bone involvement, as this enzyme is produced by osteoblasts during bone remodeling in response to myeloma-related bone destruction. Transaminase elevations, such as AST and ALT, may occur due to direct liver infiltration by plasma cells, amyloid deposition in the liver (in cases of myeloma with amyloidosis), or as a result of hepatotoxicity from medications used to treat multiple myeloma 1.
Some key points to consider when evaluating a myeloma patient with elevated liver enzymes include:
- Medication effects: Many drugs used to treat multiple myeloma can cause liver enzyme elevations, so it's essential to review the patient's medication list.
- Disease progression: Advanced multiple myeloma can lead to liver involvement, so assessing the patient's disease status is crucial.
- Comorbid conditions: Other conditions that may affect the liver, such as viral hepatitis or fatty liver disease, should be considered in the differential diagnosis.
- Rare causes: Light chain deposition in the liver, extramedullary plasmacytomas involving the liver, and hepatic vein thrombosis are less common but possible causes of liver enzyme abnormalities in myeloma patients.
When managing a patient with multiple myeloma and elevated liver enzymes, it's essential to take a comprehensive approach, considering both the disease itself and potential comorbid conditions or medication effects 1.
From the Research
Alkaline Phosphatase and Transaminases in Multiple Myeloma
- Multiple myeloma can cause elevations in alkaline phosphatase (ALP) levels, as bone involvement in the disease results from increased osteoclast formation and activity 2.
- Studies have shown that ALP levels are mainly in the range of normality in patients with multiple myeloma, compared to those with solid cancers and bone lesions 2.
- Bone-specific alkaline phosphatase (BALP) levels have been investigated as a tool for evaluating the extent of bone disease in multiple myeloma patients, and have been found to be increased in patients with osteolytic bone lesions 3, 4.
Correlation with Overall Survival
- Research has found a correlation between initial ALP levels and overall survival in newly diagnosed multiple myeloma patients, with an ALP range of 70 to <120 U/L reflecting a better survival expectation 5.
- ALP levels have been found to vary significantly among patients with different bone disease grades, and have been identified as an independent factor influencing survival in newly diagnosed patients 5.
Transaminases
- While the provided studies do not directly address the relationship between multiple myeloma and transaminases, research has found that liver function indicators, including alanine aminotransferase and aspartate aminotransferase, differ significantly among multiple myeloma patients with different ALP levels 5.
- Aspartate aminotransferase has been identified as an independent factor influencing survival in newly diagnosed multiple myeloma patients 5.