Checking ALT levels is the mainstay veterinary test for liver disease in dogs.
The typical reason of ALT elevation is liver and bile duct disease but there are other potential causes.
Further information: Why Are My Dog’s ALT Levels Abnormal?
Cookie’s wellness exam
Regular wellness exams are one of the most important things you can do for your dog. Many problems can be caught long before they cause clinical signs.
A regular health evaluation can address early dental disease, weight issues, orthopedic issues and catch a systemic disease or organ damage early.
Elevated Alanine Transferase (ALT)
Cookie’s blood work came back with elevated ALT.
Nothing crazy, just right about double the upper normal value. Her level was 218 U/L; the normal range is 10- 118 U/L). Everything else looked fine. So the question is what does it mean and is that something to worry about?
It’s certainly a reason to re-check the values again within a few weeks.
Here what her vet said. “Typically any value below 250U/L is deemed clinically insignificant, as long as other values are normal and if Cookie is clinically normal.
ALT can be increased with a self-correcting, transitory liver insult, gastrointestinal irritation (vomiting/ diarrhea etc), mild muscle injury.
Because Cookie is clinically normal, it is most likely a minor insult to her liver (ingesting a mild irritant, minor allergic reaction, etc.) or a mild muscle injury. To ensure this is a transitory issue, recheck bloodwork is recommended in 6-8 weeks or sooner if clinical signs appear (anorexia, vomiting, diarrhea, limping etc).”
Not a cause for alarm
Cookie’s vet in Fergus also felt it was nothing to be alarmed about.
“The ALT is not alarming.. had a dog go over 2000 yesterday just because I touched the liver in surgery, looking for abnormalities on the different surfaces.
A plan to follow up down the road is prudent and cautious…. at that level would not do anything more.”
It is true that Jasmine’s liver values were off the charts after her drug-induced hyperthermia and the liver healed just fine. Because of its many jobs, many things reflect in liver values.
Evaluating results in context
One thing about this is that one test provides a narrow frame in time.
It doesn’t tell us whether the value was actually on its way down, on its way up or whether it’s been lingering at this level for some time. That’s why we need to take at least one other look.
What is ALT?
ALT is short for alanine aminotransferase, which is an enzyme found primarily in the liver but also in other tissues (kidneys, heart, muscles, and pancreas). When a cell is damaged, ALT spills into the bloodstream.
In most situations, ALT is considered a liver-specific enzyme. Which means it usually reflects damage of liver cells.
Conditions that can cause this include:
- liver or bile duct disease
- trauma
- toxins
- pancreatitis
- Cushing’s disease
- corticosteroid medication
- diabetes and more … even missing a few meals can increase the ALT.
Due diligence
All we know for certain is that we need to check them out again.
Cookie seems perfectly fine. Her stool was kind of funky the day before the blood test, so perhaps she ate or drank something that caused some trouble.
If she started looking sick we’d go in right away. As it is right now, we will wait and retest and I’ll try not to worry in the meantime.
Re-testing
When we re-tested, we learned that Cookie’s ALT values remained elevated. We had to come up with a plan of action to get to the bottom of it.
The first thing we did was to test for pancreatitis since Cookie had that in the past. The test came out clean. That was some weight off my shoulder because I’ve been worried about it coming back or brewing under the surface ever since it happened.
While I thought the GI function test would be a great next step, it has turned out that doing that would be quite cumbersome.
Cookie’s vet suggested doing the ultrasound if I really wanted to do something.
Ultrasound and biopsy
The problem with that was that it does require shaving of the belly and the Winter was REALLY cold. Of course, we could put a sweater on Cookie but that would last on her for about five minutes if that long.
As much as I didn’t like it, we decided to wait for the weather to warm up a little bit. Of course, if any symptoms cropped up, we would have done it right away. I couldn’t wait too long either because I wanted Cookie’s fur to grow back before the bugs come out.
The weather finally did warm up enough and we booked Cookie for the ultrasound.
Cookie was an extremely good girl and didn’t require any sedation whatsoever neither for the ultrasound nor for the biopsy they took. They didn’t make any comments on what they saw or didn’t see, just mentioned they also did the biopsy.
So they clearly saw something, didn’t they?
Waiting for results
The hospital routinely sends the ultrasound images out for interpretation. We were told the report should come back in 24 to 48 hours.
I waited to hear back. One day passed, two days … three … I called to see whether they got the results. I was told there was nothing on file and the vet will call me when she can.
Four days passed …
Wouldn’t you get suspicious?
I started thinking there was something amiss and they were waiting for the biopsy results before talking to me. Which objectively made sense but subjectively only got me worried anyway. So they could just go ahead and tell me.
Few hours after I called for the third time, with nothing showing on the file still, I finally got a call.
The ultrasound did indeed show some minor abnormalities and they were, indeed, waiting for the biopsy results before talking to me.
What does minor abnormalities mean?
This is what the report said:
113 still abdominal ultrasound images were reviewed.
There is no evidence of free abdominal fluid. The liver may be minimally enlarged. The hepatic parenchyma is slightly mottled, with ill-defined regions of slightly increased and decreased echogenicity. There is no evidence of discrete nodules or masses, however. The gallbladder is unremarkable. There are no splenic abnormalities identified.
The kidneys are symmetric and within normal limits, with normal overall renal architecture. The visible portion of the G.I. tract is unremarkable.
Assessment:
Probable minimal hepatomegaly.
The slightly mottled echotexture of the hepatic parenchyma is a mild and nonspecific finding. Hepatitis, a variety of drug or toxin-induced hepatopathies, metabolic/endocrine disease or less likely neoplasia may all be considered. If clinically indicated, a fine needle aspirate or biopsy may be helpful.
Doesn’t really tell much other that there are some things that are a bit off. Could mean all sorts of things.
Biopsy results
Had to wait for the biopsy results to get a better idea of what’s going on.
We were out walking the dogs when the vet called about it. From the tone of voice alone I could tell it was good news. Though after reviewing the cytology report, I do have some questions.
Here is what the report said:
Smears contain numerous clusters of intact hepatocytes on a hemodiluted and mildly vacuolated (somewhat lipidic) background with few clusters of ruptured adipocytes. The hepatocytes show adequate nucleocytoplasmic ratio and contain basophilic staining, faintly granular cytoplasm. Nuclei are uniform with coarse chromatin and single distinct nucleolus. Binucleated hepatocytes are frequently identified. Leukocytes are subjectively estimated to be numerically in proportion to blood contamination. There is no evidence of atypical cells.
Microscopic findings: unremarkable liver aspirates
Comment: There are no significant cytological abnormalities to explain the biochemical changes in this patient. The hepatocytes are well-differentiated and show minimal atypia. Binucleated hepatocytes are commonly observed in liver aspirates but may be numerous in association with tissue regeneration or hyperplasia. Correlate with clinical presentation and sonographic findings. The sample is noninflammatory and there are no elements to suggest underlying neoplasia.
In other words, things look generally normal, with no evidence of inflammation or cancer. There seem to be a little more liver cells about to divide than normal. Why? Is the liver healing from something or is there something else going on?
Dig deeper or not?
There seem to be a bit more fat present than normal. Why? I still have to decide whether to dig deeper to figure out the reason behind these minor anomalies.
The vet who called me with the results said, “That’s how Cookie chooses to be.”
As I know myself, I won’t rest until I know why. If it can be figured out.
Cookie’s belly is as good as new. The fur grew back completely after her ultrasound, even before the bugs start coming out.
Because the results of the ultrasound and biopsy were neither alarming nor really conclusive in explaining the live enzyme elevation, we booked an integrative consultation to see what’s happening and what we might do to make the liver happier faster.
It was our first integrative consultation with our new vet up here.
In the meantime, Cookie was getting an adjusted diet, dandelion and milk thistle to help the liver out.
While at the vet, we decided to retest the blood values to see whether there has been an improvement.
We agreed to only run what they call a pre-op panel because all we really wanted to see was the ALT. And since we were already drawing blood we also got it tested for heartworm and tick-borne diseases as we do every spring. (Cookie is clear of all of those.)
Cookie’s ALT has gone down
It is still at high normal but it’s gone down from 225 to 104 (normal range is 10-118). That is very good news. What we’re doing was working and the liver is getting happy.
The TCVM exam also didn’t reveal that the liver would be in distress. We can discontinue the milk thistle and stick with the dandelion for the time being. We also discussed licorice, which I still have to look into some more. As far as her diet is concerned, Cookie is getting things that make for a happy liver.
It wouldn’t be my luck if I got to leave with good news only.
The pre-op panel includes a few other things, including BUN and creatinine. Those are considered a reflection of kidney function, though the BUN can be out of range for all kinds of other reasons as well.
Playing with my emotions
Both BUN and creatinine were elevated on that draw.
I’m putting freaking out on hold, though, because both the vet and myself feel there were other things at play which could have done that.
Cookie was quite stressed this time. Apparently, they just had a dog in who was attacked by other dogs and was terrified and freaking out. The vet tech who came to draw the blood was comforting and restraining him just before she walked in. As it seems, sensitive as she is, Cookie picked up on all that and it got her quite upset. She didn’t want her blood drawn, she didn’t want to be there, just wanted to get out the door.
With the trip, the weather and the stress, she was quite dehydrated at the time of the blood draw. Because she didn’t need to fast for the test we were after, she had her lunch as well as a bunch of treats.
Any combination of these things could have caused those levels to elevate.
Cookie isn’t showing any signs of a problem. The TCVM exam didn’t show any issues. The vet said that she wasn’t feeling what the lab work was showing.
I am used to one blood level or another being out of whack every now and then. As long as it’s not the same one repeatedly, as it was with the ALT.
Follow-up on new abnormalities
So, for now, I refuse to panic.
We will, however, get urinalysis done to make sure the kidneys indeed are as happy as they should be.
Serves me right for being too diligent?
Makes me think of full-body scans. The more you look, the more likely you are to find things which might not mean anything but will get your blood pressure up and do have to be checked.
Here is hoping that it was just a result of circumstances and not a true reflection of anything.
As for our new vet, I really love that she’s happy to discuss things with me. We seem to be very kindred spirits.
Related articles:
What’s In The Blood? Blood Testing And Interpretation
How far to Take It when Your Dog Isn’t Sick?
Further reading:
Why Are My Dog’s ALT Levels Abnormal?