Elevated AST/ALT enzymes, liver function panels

[mslman71]

I'm posting this as a personal account for anyone who has come back with concerns following blood tests, specifically liver function. As they say, YMMV.

I'm more of a runner/endurance guy than a lifter these days and it's pretty common for me to hit 3+ hours of pretty aggressive cardiovascular training with weight training in a given day. Addressing whether this is smart or not is not the purpose of this post. Following a typically intense week of work including a 9 mile run right before my exam I had my annual physical and blood test.

As part of that blood test my physician orders the liver function tests including AST, ALT, AP, protblood, bilirubin, etc. My AST and ALT levels came back out of normal range (about 3x of the upper limit). This would be considered mildly to moderately elevated. Being concerned my physician ordered a follow-up ultrasound, which ended up being unremarkable.

Immediately after I was given word of elevated AST and ALT levels I of course hit the books & literature to understand what they are and their source. The short version is that they are enzymes that are released from cells as a result of death of or extreme damage to the cells. They are not released as a defense mechanism but just escape when the membrane is compromised along with all the other "stuff" in there and wind up in the bloodstream. The presence of these enzymes in blood is itself not inherently dangerous.

In "normal" people elevations of AST and ALT are typically indicative of liver damage, which is why they are part of the liver function panels. It turns out that AST and ALT levels are not specific to liver cells, ALT being more specific than AST. Damage to other tissues, including skeletal muscle, can release these enzymes and cause elevated levels. There are a number of manuscripts available on pubmed and general consumption reviews on the internet discussing the relationship between elevated AST/ALT levels and endurance athletes and weight training. There is typically a 1-2 day delay before the levels begin to rise significantly and they peak after a few days. The half-life is such that it will likely take at least a week from the acute event for the levels to return to normal, assuming of course one doesn't keep repeating stresses that lead to the elevated levels.

The general feeling among physicians appears to be that the probability of elevated levels from physical activity is low and they can be dismissive of the potential contribution of it to anomalous lab results. The solution is to go easy for a week and insist on having the tests repeated. As an engineer I'm never a fan of single point measurements anyway so having multiple readings is always good (might also indicate bad handling of samples, poorly calibrated equipment, etc.).

Cliffs:
Patient: hard runner, climber, and mild weight lifter, annual physical exam
Symptoms: Elevated liver enzymes (AST/ALT) but otherwise physically asymptomatic
Concern: Potential liver damage (e.g., hepatitis, obstructed bile ducts, etc)
Action: Reduce physical activity for 10 days and followup with ultrasound and redraw blood
Resolution: AST/ALT levels returned to within normal limits
Likely cause: Intense acute or chronic physical activity caused sufficient muscle damage to elevate AST/ALT levels, AST/ALT not being liver specific

I did see here that a number of people in the "nutrition" and "supplements" sections asking about supplements to help with elevated levels. This seems nonsensical to me as either your routine causes the damage (and elevated levels themselves aren't inherently bad) and a supplement isn't going to stop it OR you have an underlying pathology of the liver (or pancreas, heart, etc) that needs to be identified and piling on chemicals is either going to do nothing or complicate the process.

[DuracellBunny]

Without looking it up, what comes to mind as an interesting avenue of investigation, is intra-workout consumption of carbs and glycogen depletion.

My biochem isn't strong enough that I carry it around in my head, but my gut says that heavy endurance exercise, raising levels from both muscle tissue and the liver, would indicate a relationship with glycogen. If such a relationship exists, then carb loading prior to exercise or consumption of short chain carbs during exercise, would logically lead to less enzyme elevation.

The studies that are mistakenly applied to weight training, about cortisol levels increasing just prior to the one hour duration mark (the studies were actually conducted on endurance athletes) could lead to further avenues of research. Try looking at the relationship between cortisol and AST/ALT.

Just a couple of thoughts.

[drudixon]

Oddly, running has far higher protein requirements than lifting. Up your protein . BTW, did you experience rhabdo?

[mslman71]

Without looking it up, what comes to mind as an interesting avenue of investigation, is intra-workout consumption of carbs and glycogen depletion.

My biochem isn't strong enough that I carry it around in my head, but my gut says that heavy endurance exercise, raising levels from both muscle tissue and the liver, would indicate a relationship with glycogen. If such a relationship exists, then carb loading prior to exercise or consumption of short chain carbs during exercise, would logically lead to less enzyme elevation.

The studies that are mistakenly applied to weight training, about cortisol levels increasing just prior to the one hour duration mark (the studies were actually conducted on endurance athletes) could lead to further avenues of research. Try looking at the relationship between cortisol and AST/ALT.

Just a couple of thoughts.

I believe the main thing is tissue damage/death that results in cell lysis or at least a greater rate of release of the enzymes from the cell into the surrounding tissue/blood. The release isn't a mediated response to a stress. I would say imagine looking through storm debris and identifying what type of store was in the damaged building by the type of contents strewn about. Some items would clearly indicate the nature of the business whereas other items would be found in most any type of building.

Oddly, running has far higher protein requirements than lifting. Up your protein . BTW, did you experience rhabdo?

I'm comfortably over 1g/lb raw body weight. No rhabdo that I know of. Saw some dark piss a time or two but not within a week of my blood tests.

[induced_drag]

Always have them test ggt with a liver panel test. Ruled out transient elevations in ensymes due to exercise. Made a thread about it a few years ago. Also included links to pubmed with study links. Save the ultrasounds and specialist referrals.

Over the years I have had test come back at 4x top of the scale. That was the worst. IIRC I had done heavy deads two days earlier. After that one my doc did ask me take it easy for a few days and retest. I did light workouts and then the last 3 days off. Tested mid range.

Now my doc just does ggt by default. I take it easier, but I still test high. I just don't feel like stopping my training just for the tests. With 7+ years of physicals showing elevated Liv, bun, creatinine....etc, my doc knows that is 'normal' for me. A guy who weight trains heavily and consumes 200+ grams of protein a day.

[Bando]

Cliffs:
Patient: hard runner, climber, and mild weight lifter, annual physical exam
Symptoms: Elevated liver enzymes (AST/ALT) but otherwise physically asymptomatic
Concern: Potential liver damage (e.g., hepatitis, obstructed bile ducts, etc)
Action: Reduce physical activity for 10 days and followup with ultrasound and redraw blood
Resolution: AST/ALT levels returned to within normal limits
Likely cause: Intense acute or chronic physical activity caused sufficient muscle damage to elevate AST/ALT levels, AST/ALT not being liver specific

Just for posterity I hope you don't mind if I add that you were a longtime vegetarian who added meat to your diet a month or so before these tests.

I don't have a dog in this fight, just thought that variable was important when discussing liver functions.

[DuracellBunny]

I believe the main thing is tissue damage/death that results in cell lysis or at least a greater rate of release of the enzymes from the cell into the surrounding tissue/blood. The release isn't a mediated response to a stress. I would say imagine looking through storm debris and identifying what type of store was in the damaged building by the type of contents strewn about. Some items would clearly indicate the nature of the business whereas other items would be found in most any type of building.



I'm comfortably over 1g/lb raw body weight. No rhabdo that I know of. Saw some dark piss a time or two but not within a week of my blood tests.

I would still examine cortisol as an attributory factor. Elevated cortisol levels affect fat in the liver. Look up cushings disease and fatty liver disease. Any cause of elevated cortisol can lead to fatty liver, not just cushings, and effects can be transient. If you are training 3 hours a day, you have elevated cortisol, there are no ifs or buts about it.

[mslman71]

Just for posterity I hope you don't mind if I add that you were a longtime vegetarian who added meat to your diet a month or so before these tests.

I don't have a dog in this fight, just thought that variable was important when discussing liver functions.

For posterity, noted and appreciated.

There's no biochemical reason that I can think of where this would matter however I resumed eating meat in March IIRC and the test was in July and the elevated levels returned to normal after a week of relatively sedentary activity.

I'll also add that during that week of sedentary activity I was vacationing in New Orleans and doing a damn fine job of stretching my meat eating my wings with all the good food that was available .

[Saucha]

I have had elevated ALT before. At the time I was taking a chit load of nutritional supplements and thyroid meds. I stopped all for 6 weeks then reintroduced the thyroid plus a few select supps and now it's normal again. Maybe not relevant for you but who knows.

[mslman71]

I have had elevated ALT before. At the time I was taking a chit load of nutritional supplements and thyroid meds. I stopped all for 6 weeks then reintroduced the thyroid plus a few select supps and now it's normal again. Maybe not relevant for you but who knows.

Good info. In my case I take no supplements other than a plain multivitamin in the AM and 5-10mg of melatonin in the PM and am on no medications other than 400mg or less ibuprofen (as req'd) daily.

[mslman71]

Always have them test ggt with a liver panel test. Ruled out transient elevations in ensymes due to exercise. Made a thread about it a few years ago. Also included links to pubmed with study links. Save the ultrasounds and specialist referrals.

Over the years I have had test come back at 4x top of the scale. That was the worst. IIRC I had done heavy deads two days earlier. After that one my doc did ask me take it easy for a few days and retest. I did light workouts and then the last 3 days off. Tested mid range.

Now my doc just does ggt by default. I take it easier, but I still test high. I just don't feel like stopping my training just for the tests. With 7+ years of physicals showing elevated Liv, bun, creatinine....etc, my doc knows that is 'normal' for me. A guy who weight trains heavily and consumes 200+ grams of protein a day.

I wouldn't have thought much of the elevated levels if I hadn't also had some IBS-like symptoms off-and-on AND with AST/ALT levels being dead center "normal" for the previous four years. That is, I was mostly alerted to the change. Alternatively I don't think I've ever had BUN levels fall within normal range.

[Bando]

I was vacationing in New Orleans and doing a damn fine job of stretching my meat eating my wings

How are the wings in New Orleans? We have great wings here and I love the Cajun style but my wife hates them so I never order them.

I imagine in NO they must be out of this world.