Elevated Liver Enzyme [alt]

[Skruffy n Flea]

earlier this year, i had bella's blood tested [generally] and i was told that one liver enzyme [ALT] was slightly elevated.

i had her in for a followup test this past wednesday and it had risen by 110 points [it was 229, now 339].

the vet told me that because bella is part maltese, a bile test would be inconclusive and could offer no particular reason for the initial rise or even the elevation since.

so another test in about a month and depending on those results, followed by an ultrasound.

has anyone had an experience in this regard with their dog? can you tell me what the likely cause was? what you did to re-establish the enzyme to within the normal range?

thanks

[SchnauzerMax]

earlier this year, i had bella's blood tested [generally] and i was told that one liver enzyme [ALT] was slightly elevated.

i had her in for a followup test this past wednesday and it had risen by 110 points [it was 229, now 339].

the vet told me that because bella is part maltese, a bile test would be inconclusive and could offer no particular reason for the initial rise or even the elevation since.

so another test in about a month and depending on those results, followed by an ultrasound.

has anyone had an experience in this regard with their dog? can you tell me what the likely cause was? what you did to re-establish the enzyme to within the normal range?

thanks

Snf,

what is the normal range for this enzyme?

[JulesP]

Not sure why the vet is saying that about the bile test? Lots of people on my liver list have bile tests down with their little dogs.

A bile test will only show if there is a problem though.

A ultrasound might not pick up anything either, especially one down by a normal vet.

A high reading could be heaps of things. It could be something the dog is eating. It could be something serious.

Does Bella have any symptoms at all? some would be: fussy eater, tummy problems, problems putting on weight, poor coat, pacing for no reason, pressing her head against things, swollen belly.

To see if you can drop the ALT levels I would adjust her diet. The easiest way to do this is to feed Hills L/D. A homemade diet would feature egg whites & cottage cheese for protein, some veggies and rice. No animal protein so the liver has a break.

My dog presented to the vets with a swollen tummy. A ultrasound of her heart showed a tiny liver, her ALT reading was 268. The next thing we did was a bile test which came back in the abnormally high range. I was then sent to a specialist who luckily found the problem via ultrasound (I say luckily as it was the cheapest option). Amber has multiple liver shunts.

[Skruffy n Flea]

Snf,

what is the normal range for this enzyme?

hi and thanks

i think i read somewhere that it was 10-100 --- i'm looking again at the sites i've been reading to confirm that.

[Skruffy n Flea]

hi jules and thanks

Not sure why the vet is saying that about the bile test? Lots of people on my liver list have bile tests down with their little dogs.

she said it had to do with the maltese breed but she didn't go into detail, saying that because of that, the test would be inconclusive.

A bile test will only show if there is a problem though.

A ultrasound might not pick up anything either, especially one down by a normal vet.

yeah, she said that too, but added that it may reveal a shunt! i'm looking into that too.

A high reading could be heaps of things. It could be something the dog is eating. It could be something serious.

yeah, the sites i've looked at give absolutely no indication whatsoever --- one site however did claim that it meant hepa-frikken-titis! closed that site pretty darned quickly...

Does Bella have any symptoms at all? some would be: fussy eater, tummy problems, problems putting on weight, poor coat, pacing for no reason, pressing her head against things, swollen belly.

none of the above EXCEPT if scooching over blankets and under pillows would amount to pressing her head against things!?!?

To see if you can drop the ALT levels I would adjust her diet. The easiest way to do this is to feed Hills L/D. A homemade diet would feature egg whites & cottage cheese for protein, some veggies and rice. No animal protein so the liver has a break.

actually, the vet nurse spoke briefly about L/D as well and i was thinking at that time that it may be the level of protein in her food --- i don't know how she'd go on the homemade diet you suggest but it's gotta be cheaper than L/D so i'll see how she goes on that. thanks for suggesting it

My dog presented to the vets with a swollen tummy. A ultrasound of her heart showed a tiny liver, her ALT reading was 268. The next thing we did was a bile test which came back in the abnormally high range. I was then sent to a specialist who luckily found the problem via ultrasound (I say luckily as it was the cheapest option). Amber has multiple liver shunts.

268! bella's is 339! holy crap!

[JulesP]

none of the above EXCEPT if scooching over blankets and under pillows would amount to pressing her head against things!?!?

Really don't want to say this but this actually can be a symptom of liver problems

I'll find the diet and post it for you.

Low sodium is important as is low purine (dogs with liver issues can have urinary issues too). Low copper too at this stage is important.

[JulesP]

Here is Jean Dodds liver diet - http://www.canine-epilepsy-guardian-angels.com/liver_diet.htm

Instead of the fish use egg whites.

It is important to feed lots of little meals. There are heaps of supplements (milk thistle, SAMe) and other medical treatments (antibiotics, diuretics, lactulose) but probably best to get a diagnosis first.

[Skruffy n Flea]

none of the above EXCEPT if scooching over blankets and under pillows would amount to pressing her head against things!?!?

Really don't want to say this but this actually can be a symptom of liver problems

srsly!??! she's been doing that since she was a pup, generally after she's been bathed or when she's being cheeky and playful! byron does that too altho not to the same extent...

I'll find the diet and post it for you.

Low sodium is important as is low purine (dogs with liver issues can have urinary issues too). Low copper too at this stage is important.

low sodium i understand, but i'll have to research purine and copper

Here is Jean Dodds liver diet - http://www.canine-epilepsy-guardian-angels.com/liver_diet.htm

thank you so much jules! i came across this diet earlier and was expecting to go look for it again; low and behold, you've done it all for me :D

Instead of the fish use egg whites.

she doesn't mind white fish, so i might start her off with that and slowly wean her onto the egg whites. so, it would be 2 cups of [cooked] egg whites, right?!? and what about the biotin issue? isn't it that the white should not be fed without the yellow?!?

It is important to feed lots of little meals. There are heaps of supplements (milk thistle, SAMe) and other medical treatments (antibiotics, diuretics, lactulose) but probably best to get a diagnosis first.

i'm going to investigate the milk thistle; what is SAMe tho?

jules, thank you so much for your help

[Skruffy n Flea]

purines:

... are natural substances found in all of the body's cells, and in virtually all foods. The reason for their widespread occurrence is simple: purines provide part of the chemical structure of our genes and the genes of plants and animals. A relatively small number of foods, however, contain concentrated amounts of purines. For the most part, these high-purine foods are also high-protein foods, and they include organ meats like kidney, fish like mackerel, herring, sardines and mussels, and also yeast.

copper [still a little uncertain]:

copper requirements in dogs

ps: altho the attachment doesn't show in my post preview, it did when i clicked on it

[Skruffy n Flea]

SAMe [i think i'll leave this one out of the equation] and milk thistle: about mid-way down the page

[Rappie]

Elevations in ALT reflects damage to the cells of the liver. The size of the elevation doesn't necessarily reflect the severity of damage or the reversibility of damage, although generally speaking larger numbers indicate more significant disease (200 compared to 1000 etc). In the absence of clinical disease, it is more important to monitor trends, a continuing upwards trend is a reason to investigate further. Although ALT indicate the liver is involved, there are several things that can make ALT go up like drug treatment, toxin exposure, hypoxia as well as liver disease.

Maltese can have a higher resting bile acids level than other dogs, so elevations may or may not be significant.

If you have an increasing trend the options are:

- investigate --> blood tests (bile acids, ammonia tolerance test though this is less commonly done and not without risk), abdominal ultrasound to look for shunts and physical changes / nodules / masses within the liver. Further investigation is usually in the form of a biopsy - sometimes done under sedation with ultrasound guidance, or done via an exploratory surgery.

- treat symptomatically --> liver diets, antioxidants / neutraceuticals like SAMe, silymarin, Vit E.

Which path is chosen usually depends on a number of factors including the age and breed of the patient, whether there are clinical signs (or it was an incidental finding), whether there were any other abnormalities and how much investigation you are prepared to do to determine the cause.

[Skruffy n Flea]

hi rappie and thanks for your input

Elevations in ALT reflects damage to the cells of the liver. The size of the elevation doesn't necessarily reflect the severity of damage or the reversibility of damage, although generally speaking larger numbers indicate more significant disease (200 compared to 1000 etc).

so, bella's level of 339, altho high, isn't necessarily significant with regard to severity. this likely accounts for the vet's lack of urgency, for want of a better phrase? i say that because the vet gave no indication that she considered the elevation that serious, despite the level having increased 110 points in the past 8 months and it being in the absence of any other elevated enzyme. does that make sense!??!

In the absence of clinical disease, it is more important to monitor trends, a continuing upwards trend is a reason to investigate further. Although ALT indicate the liver is involved, there are several things that can make ALT go up like drug treatment, toxin exposure, hypoxia as well as liver disease.

no clinical disease [on physical examination, heart fine, no liver, stomach (kidney and or spleen!?!?) swelling, no swelling in the throat (thyroid!??!)] no drug treatment; that leaves toxin exposure, hypoxia and liver disease. fwiw and having read thru this site, i'd hazard the guess it's likely (dry food) toxins.

Maltese can have a higher resting bile acids level than other dogs, so elevations may or may not be significant.

given that bella [i verily believe] is F1 jack/maltese, is it possible that her maltese'ness could account for the elevation [does it account for the continued elevation tho]!?? i only say this because the vet intimated the possibility and the same has been said about my white blood cell count in that it's consistently high for no apparent reason and that it's likely just how i am biologically!

If you have an increasing trend the options are:

- investigate --> blood tests (bile acids, ammonia tolerance test though this is less commonly done and not without risk), abdominal ultrasound to look for shunts and physical changes / nodules / masses within the liver. Further investigation is usually in the form of a biopsy - sometimes done under sedation with ultrasound guidance, or done via an exploratory surgery.

the vet and i talked about an ultrasound and of course the bile acid test and she did mention the prospect of a liver biopsy.

- treat symptomatically --> liver diets, antioxidants / neutraceuticals like SAMe, silymarin, Vit E.

i'm willing and able to change her diet to that provided by dr dodds; as for supplements, i'm going to need assistance. right now i lack confidence because as much as i've researched and given my dogs and cat the best possible chance at a good and healthy life, it seems my efforts have been in vain and so i'm going to require some hand-holding --- this thing with bella and a week ago, it was just short of a grand for byron's dental work; all on my watch...

Which path is chosen usually depends on a number of factors including the age and breed of the patient, whether there are clinical signs (or it was an incidental finding), whether there were any other abnormalities and how much investigation you are prepared to do to determine the cause.

she turned 3 in july and the finding was incidental [following her first ever summer buzz cut in nov 2010, regrowth over her thighs was slow and altho most of her fur has slowly regrown, her pants are still knee length; the vet noticed it only after i'd pointed it out to her].

she's my baby girl, my heart dog, and i am prepared to investigate this until it's resolved.

thanks again rappie, i really appreciate the help

[Rappie]

No problem

You're on track with your assessment of Bella's levels - a continued increase in ALT over time is something to take note of, but the number isn't that exciting in an otherwise clinically normal dog. The liver enzymes are different to the bile acids, so a higher ALT is probably not breed related but different individuals can have different resting levels (the normal ranges are like a bell curve).

The most common courses of action in my experience (and these are by no means the only options, so speak to your vet obviously) are:

- continue to monitor over 3-6 months, sometimes they will go down again. Continuing upwards is an indication for investigation.

- give a course of SAMe, it has a recognised antioxidant activity and can reduce liver enzymes. I would generally start with Denosyl (a veterinary formulation) and then retest after a few weeks. It may not be necessary to repeat or continue it after that.

- go ahead with an ultrasound to rule out structural disease or shunts. Normal findings don't rule out microscopic disease (like microvascular dysplasia, toxicities) but they do rule out a lot of scary things.

There's not one single 'best' way to approach this situation. It is quite common for us to do a general blood profile and find a small abnormality incidentally. Monitoring is a perfectly acceptable thing to do initially. The main thing is that you discuss your concerns with your vet so that you feel comfortable with the level of information (by this I mean diagnostic information - blood tests, ultrasounds etc) you have.

Edit to add: It's important to remember that you have a clinically normal dog with a biochemical abnormalitiy. This doesn't mean that she definitely has liver disease so talk to your vet before putting her on a protein restricted diet as it might not be indicated at this stage.

Edited November 12, 2011 by Rappie

[JulesP]

With egg whites it would be about 2 egg whites a day for a little dog.

[Skruffy n Flea]

hi rappie, hi jules this is the first opportunity i've had this week to come in and reply --- i did read your posts earlier in the week, but time wasn't on my side...

again, thank you both so much for your input

as to diet and altho i was ready to go the egg whites and cottage cheese [and or some white fish] i had a moment of clarity and decided, at this juncture, to just reduce the amount of complex proteins and see what her bloods tell us next time --- i've had another chat to the vet and they agree that would be a good first step...

for brekkie, it's 30g blackhawk with about 20g pulped raw greens and grated carrot and then at night, 30g [down from about 50g of dr b's barf] of raw cubed [human grade] lamb andor beef or chicken with 30g of pulped raw greens and grated carrot [adding a small tspn of omega pet oils and ACV with about a half tspn of low fat cottage cheese]...

immediately after their dinner, they each get 1/3 [in 2 bits] of a teenie greenie and i'm working into both dogs' diet an amount of RC dental [just started that today]...

during the day and instead of raw bones both dogs chew on petbarn dried beef tendons and [96% fat free] dried cow ears...

i've cut out their petbarn dried beef gullet chews and reduced their beef liver treats...

about 6 weeks ago i removed [as much as i cold] carbs from their diet due to a yeast burden.

i realise i provided more info than likely necessary but it helps me to form a 'food map' in my head

i'll be having her bloods done again by mid-december so we'll see then whether these changes have any effect...

again, i can't thank you both enuf

i have another issue with bella but that's a whole 'nother thread *blimey*

[Skruffy n Flea]

hello

bloods taken yesterday and the result is bella's alt enzyme has elevated to 596 [up from 339] --- to say that i'm feeling a wee bit afraid for her would be an understatement...

i've now printed up dr dodds' liver diet and taken notes of the egg white/cottage cheese diet anticipating that i will discuss these with bella's vets. i've also noted the foods to avoid.

...

The most common courses of action in my experience (and these are by no means the only options, so speak to your vet obviously) are:

- continue to monitor over 3-6 months, sometimes they will go down again. Continuing upwards is an indication for investigation.

next blood test scheduled for january.

- give a course of SAMe, it has a recognised antioxidant activity and can reduce liver enzymes. I would generally start with Denosyl (a veterinary formulation) and then retest after a few weeks. It may not be necessary to repeat or continue it after that.

i'd forgotten about SAMe, so will talk with the vet about it when we discuss changing bella's diet

- go ahead with an ultrasound to rule out structural disease or shunts. Normal findings don't rule out microscopic disease (like microvascular dysplasia, toxicities) but they do rule out a lot of scary things.

There's not one single 'best' way to approach this situation. It is quite common for us to do a general blood profile and find a small abnormality incidentally. Monitoring is a perfectly acceptable thing to do initially. The main thing is that you discuss your concerns with your vet so that you feel comfortable with the level of information (by this I mean diagnostic information - blood tests, ultrasounds etc) you have.

Edit to add: It's important to remember that you have a clinically normal dog with a biochemical abnormalitiy. This doesn't mean that she definitely has liver disease so talk to your vet before putting her on a protein restricted diet as it might not be indicated at this stage.

the vet found no clinical abnormality at all and this one [different vet, same surgery] also said that her alt levels were still considered on the low/medium side of high and so no dire concern!!!

rappie, thanks again for your advice

With egg whites it would be about 2 egg whites a day for a little dog.

hi jules, would you mind listing here the ingredients you used and how you prepared them? thanks

i'm also going to describe to the vet bella's smooching thing [viz head pressing] but byron does it also and he has no enzyme elevations --- better being safe than sorry

jules, thanks to you also for your input

[Ptolomy]

Earlier this year (April) my 8 year old toller became unwell, vomiting, lethargic, jaundiced, and wouldn't eat, and was diagnosed with liver failure. I can't find his initial blood tests but 4 weeks after he was diagnosed his ALT was 1087 (the reference range was 21-142.) ALT 1087 U/L 21 - 142

He was put on a low protein diet (no red meat at all), SaME and Milk Thistle. We had an ultrasound of his liver performed to rule out anything sinister.

Happy to report that September this year all his liver enzymes were back in the reference range. We still don't know the cause but due to his recovery, feel strongly that it was a poisoning of some sort - just don't know how, where, or what.

Good luck in finding answers.

Edited December 10, 2011 by Ptolomy

[JulesP]

hi jules, would you mind listing here the ingredients you used and how you prepared them? thanks

Amber is too sick for the homemade diet. She is on Hills L/D tinned and dry.

[MalteseLuna]

Hi there!

I have a Maltese with a history of elevated ALT levels. Apparently Maltese often have higher ALT levels than other breeds, and abnormal Bile Acid Test results (my vet told me this), this is likely the 'norm' for the breed and as long as not associated with any other clinical signs isn't a reason for panic.

I would recommend taking your dog to the vets at Sydney University Vet Hospital - they have some of the leading experts in canine liver function ( & one of the best liver shunt surgeons). I wouldn't be doing any biopsy, ultrasound, medication etc without talking to one of the specialists at Sydney Uni vet. My usual vet wanted to push me into a biopsy, ultrasound, diet change (onto the L/D Hills diet) etc despite no other clinical signs of a shunt or liver issues.

I still monitor her ALT levels on a yearly basis but after taking a course of medication prescribed by the specialist Luna has had no problems & her ALT levels have stabilized - still elevated but what we think is "normal" for her.

I would really emphasize a previous statement made - It's important to remember that you have a clinically normal dog with a biochemical abnormalitiy. This doesn't mean that she definitely has liver disease so talk to your vet before putting her on a protein restricted diet as it might not be indicated at this stage.

The increasing trend is a sign that a trip to a specialist is in order - in my opinion. I just don't think that normal vets are equipped to deal with highly specialized scenarios - same reason we have specialists in human doctors.

Besides liver disease there are also environmental conditions (stress, toxins etc), bacterial infections etc etc which can cause elevated ALT levels.

I wish you luck!

[Skruffy n Flea]

i spoke with bella's vet this morning and she says there'd be no harm in altering her diet but recommended that i alternate between fish/veg, whole egg/cottage cheese/veg, and her usual diet [meat/veg], to avoid any chance of her diet becoming deficient. the plan is to reduce the meat/veg to say twice/three times a week with the rest made up of the other two.

i'll talk with her about SAMe next time if bella's levels haven't dropped or at least stabilised.

i've read lately too about the possible toxicity of dry food ingredients...

Earlier this year (April) my 8 year old toller became unwell, vomiting, lethargic, jaundiced, and wouldn't eat, and was diagnosed with liver failure. I can't find his initial blood tests but 4 weeks after he was diagnosed his ALT was 1087 (the reference range was 21-142.) ALT 1087 U/L 21 - 142

He was put on a low protein diet (no red meat at all), SaME and Milk Thistle. We had an ultrasound of his liver performed to rule out anything sinister.

Happy to report that September this year all his liver enzymes were back in the reference range. We still don't know the cause but due to his recovery, feel strongly that it was a poisoning of some sort - just don't know how, where, or what.

Good luck in finding answers.

thanks for your reply and wow, i'm glad all turned out well for you both with bella showing no outward signs of illness at all i am perplexed as to why her alt levels are continuing to elevate...

as to the poisoning [or perhaps toxicity], did you feed your boy dry food!?!?

hi jules, would you mind listing here the ingredients you used and how you prepared them? thanks

Amber is too sick for the homemade diet. She is on Hills L/D tinned and dry.

thanks and i'm sorry to hear that amber is that sick i hope it's going well

Hi there!

I have a Maltese with a history of elevated ALT levels. Apparently Maltese often have higher ALT levels than other breeds, and abnormal Bile Acid Test results (my vet told me this), this is likely the 'norm' for the breed and as long as not associated with any other clinical signs isn't a reason for panic.

I would recommend taking your dog to the vets at Sydney University Vet Hospital - they have some of the leading experts in canine liver function ( & one of the best liver shunt surgeons). I wouldn't be doing any biopsy, ultrasound, medication etc without talking to one of the specialists at Sydney Uni vet. My usual vet wanted to push me into a biopsy, ultrasound, diet change (onto the L/D Hills diet) etc despite no other clinical signs of a shunt or liver issues.

I still monitor her ALT levels on a yearly basis but after taking a course of medication prescribed by the specialist Luna has had no problems & her ALT levels have stabilized - still elevated but what we think is "normal" for her.

I would really emphasize a previous statement made - It's important to remember that you have a clinically normal dog with a biochemical abnormalitiy. This doesn't mean that she definitely has liver disease so talk to your vet before putting her on a protein restricted diet as it might not be indicated at this stage.

The increasing trend is a sign that a trip to a specialist is in order - in my opinion. I just don't think that normal vets are equipped to deal with highly specialized scenarios - same reason we have specialists in human doctors.

Besides liver disease there are also environmental conditions (stress, toxins etc), bacterial infections etc etc which can cause elevated ALT levels.

I wish you luck!

hi and thank you so much for your input

following each of the three tests, the attending vet [at each point] did inform me that the elevation was not particularly concerning and the second vet did tell me that her being part maltese would indicate some elevation from the norm in any event and i understand that bella's latest [596] is still considered in the low to medium range of high. irrespective, i am concerned in that no-one can put their finger on what could be causing the continued upward trend. if her next blood test [scheduled in january] shows further elevation i will seek a referral to SUVH so thank you for reminding me that there are specialists out there

i was reading a 'liver disease' site [i can't find the damn thing now], which indicates that [some] dry food ingredients are or can become toxic --- i took note but didn't delve too far into it, but i feed my dogs [and cat] a small quantity of dry food each morning, so i have that to consider as well.

thanks again for your helpful post

as an aside, my OH tells me that his blood results show increased alt levels following a gym session and that is [apparantly] due to the breakdown of muscle cells and tissue after having been worked during strenuous exercise [when i research elevated alt levels in dogs, one of the words that keeps coming up is necrosis and that scares the bejayzuz out of me cuz to me that means dead and or dying and my OH said that made sense to him!]

if there is any correlation, i don't overly exercise my dogs, in fact they are quite sedentary and a daily walk could be anywhere between [usually] 20 minutes/a half hour to say [rarely] 45! i am suspicious tho that she is feeling some discomfort in both thigh regions --- she licks both the inside and outside areas of each and munches along the bone edge of each; she has visible fur growth lines on each, roughly in the same place but the vets don't consider there to be any connection [just something in the forefront of my mind]...

thanks again