How to investigate mildly elevated liver transaminase levels

Mild elevations in the liver enzymes alanine transaminase (ALT) and aspartate transaminase (AST) are commonly found in asymptomatic patients.

The most common cause is nonalcoholic fatty liver disease (sometimes called nonalcoholic steatohepatitis or NASH), which can affect up to 30% of the U.S. population.

Other common liver causes include:

- alcoholic liver disease
- medication-associated liver injury
- viral hepatitis (hepatitis B and C)
- hemochromatosis



Pale stool and dark urine (click to enlarge the images). This is an example of "obstructive" jaundice with the classic constellation of tea-colored urine and clay-colored stool.

Less common liver causes include:

- alpha-1-antitrypsin deficiency (AAT)
- autoimmune hepatitis
- Wilson disease

Extrahepatic conditions can also cause elevated liver transaminase levels:

- thyroid disorders
- celiac disease
- hemolysis
- muscle disorders

Initial testing should include:

- fasting lipid profile (FLP)
- measurement of glucose
- serum iron and ferritin; total iron-binding capacity (TIBC)
- hepatitis B surface antigen and hepatitis C virus antibody

If above test results are normal, a trial of lifestyle modification is appropriate.

Additional testing may include:

- ultrasonography (USG) of liver
- alpha-1-antitrypsin (AAT) and ceruloplasmin
- serum protein electrophoresis (SPEP)
- antinuclear antibody (ANA), smooth muscle antibody (ASMA), and liver/kidney microsomal antibody type

GI evaluation and possible liver biopsy is recommended if transaminase levels remain elevated for more than 6 months.

References:

Causes and evaluation of mildly elevated liver transaminase levels. Oh RC, Hustead TR. Am Fam Physician. 2011 Nov 1;84(9):1003-8.

Tobacco Smoke by Any Other Name Is Still as Deadly: Association of Pipe and Cigar Use With Cotinine Levels, Lung Function, and Airflow Obstruction

In a study of 3528 participants, 9% reported pipe smoking, 11% reported cigar smoking, and 52% reported cigarette smoking.

Self-reported current pipe and cigar smokers had elevated urine cotinine levels compared with never-smokers.

Participants who smoked pipes or cigars had increased odds of airflow obstruction.

Pipe and cigar smoking increased urine cotinine levels and was associated with decreased lung function and increased odds of airflow obstruction, even in participants who had never smoked cigarettes.

References:
http://www.annals.org/content/152/4/201.short
http://www.annals.org/content/152/4/259.short
Image source: Wikipedia, public domain.

Low vitamin D levels in children associated with higher plasma glucose and lower HDL

Vitamin D is a steroid hormone and a component of a complex endocrine pathway sometimes called 'vitamin D endocrine system' (Medscape, 2012).  A retrospective record review of pediatric outpatients (age, 2-18 years) included simultaneous measurement of 25-hydroxyvitamin D (25[OH] D) and fasting plasma glucose or 25(OH) D and a lipid panel.

25(OH) D levels were inversely correlated with fasting plasma glucose levels.

Lower 25(OH) D levels were also associated with lower serum high-density lipoprotein cholesterol (HDL) concentrations.

Children who were vitamin D insufficient (25[OH] D ≤30 ng/mL) had higher fasting plasma glucose and lower HDL levels than children who were vitamin D sufficient (25[OH] D >30 ng/mL).

References:
http://www.jpeds.com/article/PIIS0022347609009858/abstract

Monounsaturated fats found in vegetable oils, nuts and avocados increase "good" HDL cholesterol levels by 12% http://goo.gl/GBQa5

Image sources: Wikipedia, public domain.

Serotonin Blocker May Build New Bone in Osteoporotic Mice by Decreasing GI Serotonin Levels

From WebMD:

When investigators treated mice with an experimental drug that stopped the gut from synthesizing serotonin, they were able to reverse severe bone loss and essentially cure osteoporosis in the animals.



Serotonin May Hold Key to Halting Osteoporosis. NatureVideoChannel — February 05, 2010 — A drug that reverses osteoporosis in mice looks like a promising candidate for treating the human version of the disease. Gerard Karsenty and his colleagues at Columbia University Medical Center have shown that blocking the neurotransmitter serotonin--secreted from the gut--promotes bone growth. The research appears on-line at www.nature.com/naturemedicine - Yadav et al. Nature Medicine, 7 February 2010. DOI: 10.1038/nm.2098.

Most bone treatments work to block bone loss and make existing bone stronger. One drug, Forteo (teriparatide), does build new bone, but it requires daily injections and is limited to two years of use.

References:
Serotonin May Be a Key to Treat Osteoporosis. WebMD.

Diet: For every 1% increase in omega-3 intake, HDL levels rise by 2.5 mg/dL

HDL levels lower than 40 mg/dL are considered a risk factor for heart disease, while levels of 60 mg/dL or higher are thought to be optimal.

Omega-3 fats, for instance, have been linked to lower risks of age-related vision loss and dementia among older adults.

Fish Oil Comes from “The Most Important Fish in the Sea”: Menhaden

Nearly every fish a fish eater likes to eat eats menhaden (shown here). Bluefin tuna, striped bass, redfish and bluefish are just a few of the diners at the menhaden buffet. All of these fish are high in omega-3 fatty acids but are unable themselves to synthesize them. The omega-3s they have come from menhaden.

References:

Diet changes improve older adults' cholesterol too | Reuters.
http://www.reuters.com/article/idUSTRE61I49N20100219

Fish Oil Comes from “The Most Important Fish in the Sea”: Menhaden

Monounsaturated fats found in vegetable oils, nuts and avocados increase "good" HDL cholesterol levels by 12% http://goo.gl/GBQa5
How We Eat: Analyzing Half a Million Meals - 5 INFOGRAPHICS

Image source: Menhaden B. tyrannus from the Chesapeake Bay. Wikipedia, Brian.gratwicke, Creative Commons Attribution 2.5 License.

Eating chocolate with high flavanol levels can protect the skin from UV light

Cocoa beans fresh from the tree are exceptionally rich in flavanols. Unfortunately, during conventional chocolate making, this high antioxidant capacity is greatly reduced due to manufacturing processes.

The researchers evaluated the photoprotective potential of chocolate consumption, comparing:

- conventional dark chocolate
- specially produced chocolate with preserved high flavanol (HF) levels.

A double-blind in vivo study in 30 healthy subjects was conducted, 15 subjects were randomly assigned to either a high flavanol (HF) or low flavanol (LF) chocolate group and consumed a 20 g portion of their allocated chocolate daily.

The minimal erythema dose (MED) was assessed at baseline and after 12 weeks.

In the high flavanol (HF) chocolate group the mean MED more than doubled after 12 weeks of chocolate consumption, while in the LF chocolate group, the MED remained without significant change.

The authors concluded that regular consumption of a chocolate rich in flavanols confers significant photoprotection and can thus be effective at protecting human skin from harmful UV effects. However, conventional chocolate has no such effect.


Video: Chocolate Rain by Tay Zonday.

References:
Eating chocolate can significantly protect the skin from UV light. Williams S, Tamburic S, Lally C. J Cosmet Dermatol. 2009 Sep;8(3):169-73.
Link via @DrShock.

Photo Essay: Making Chocolate in Belize http://goo.gl/2DPi
Chocolate linked to substantial reduction in risk of cardiometabolic disorders but evidence not of best quality. BMJ, 2011.
Image source: Wikipedia.

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