1. Interpreting Your Liver Test Results Sumeet Asrani MD MSc Hepatologist Baylor University Medical Center, Dallas April 2015

2. Elevated liver tests Most patients with PSC have elevated liver tests Liver test elevation does NOT always imply that things are getting worse The context of elevation is very important

3. Liver function tests not specific other disease, drugs may causes elevations hemolysis, muscle breakdown(AST) hemolytic anemia or blood problems (bilirubin) not sensitive serious liver disease without elevation in LFT’s

4. Liver function Liver tests AST/ALT Bilirubin/Alkalin e phosphatase Albumin Non liver tests Creatinine INR Platelets

5. Bilirubin

6. HIGH BILIRUBIN occurs due to one or more of the following overproduction (hemolysis) impaired metabolism (chronic liver disease, rare metabolic defects) impaired excretion (biliary obstruction)

7. Bilirubin Normal bilirubin 1 mg/dL. Usually there is some elevation 1-2 mg/dL. HIGH BILIRUBIN causes Jaundice Scleral Icterus

8. Alkaline phosphatase mechanism of increase in serum alkaline phosphatase is increased enzyme production by hepatocytes induced by bile acids which may cause leakage into blood normal is around 150

9. Aminotransferases (AST/ALT) Also called SGOT/SGPT increased serum aminotransferase levels caused by injury to enzyme-rich tissue enzyme-rich tissue liver heart Muscle Normal is around 40

10. Aminotransferases AST ALT AST ALT Hepatocyte (Liver cell) AST and ALT leak into blood from damaged cells hepatocyte

11. Elevated Liver tests Is it real? Recheck Is the patient symptomatic? Did we just happen to check it Stage of liver disease? No scarring or some scarring Cirrhosis Post transplant Related to PSC or not related?

12. Location Non liver related

13. Pattern Increased AST/ALT Liver injury Increased Bilirubin/Alkaline phosphatase Bile duct injury

14. Context: Advanced Disease HIGH Bilirubin HIGH Creatinine HIGH INR LOW Platelets LOW Albumin Liver function Liver tests AST/ALT Br/AP Albumin Non liver tests Creatinine INR Platelets

15. Bilirubin going up: PSC related causes Medication? Infection? Blockage? Stone Stricture

16. Explaining elevated liver tests History and physical Blood Tests Imaging ERCP or PTC Biopsy

17. MELD score Mathematical model Bilirubin Creatinine INR http://reference.medscape.com/calcula tor/meld-score-end-stage-liver- disease

18. MELD score MELD 28MELD 16

19. Joe and Mike: compensated cirrhotics in the community MELD 28MELD 16

20. Current system: Why does Mike get the liver? MELD c statistic: 0.87 MELD 28MELD 16

21. Other tests: CA 19-9 CA 19-9 Tumor marker Can be elevated without other reasons Sometimes even a blockage can cause this number to go high

22. Other tests: PSC after LT Multiple reasons for elevation Weight gain: fatty liver Medication side effects NOT always imply recurrence Transplant center intimately involved in interpretation

23. Elevated liver tests Some elevation in liver tests is common Elevation is not simply an on/off position Context, pattern and trend is very important

24. Interpreting Your Liver Test Results Sumeet Asrani MD MSc Hepatologist Baylor University Medical Center, Dallas April 2015