elevated liver enzymes

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mustafa811
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elevated liver enzymes

Post by mustafa811 » Thu Dec 26, 2019 10:41 am

the cat past history you can jump directly to the recent problem down the post :
my cat is a 14 years old female that weighs 3.5 kg and lives strictly indoors, she used to eat friskies dry food all her life and the bowl was always full and filled so she can eat whenever she wants

when she reached 11 she had an incident of constipation in which she was examined by a vet that recommended presenting food in multiple smaller meals ,converting to royal canine which was a better alternative and introducing wet food , and the cat improved

a year later she started to drink alot and pee alot , since i am a physician i tried to measure its blood sugar with my glucometer and it was HI which is more than 550 mg/dl, we went to the vet and he advised to use royal canin diabetic formula , we used it for 2 weeks and sugar dropped from above 550 to 450 mg/dl, and the cat hind legs started to fail to jump, went to multiple vets and the only thing they did was recommending royal canin diabetic formula

anyway since i am a physician i started googling and discovered that cats can be put on our lantus insulin but with different metabolic curves , i also googled for the least carbohydrate foods out there and their availability in Egypt which was very hard since our pet market here is very limited in choices

some would ask me why didn't you turn to raw food , well i tried and the cat was very picky and she was refusing the food whatever we did

anyway after 4 months of low carb wet food and insulin the cat was almost diabetic free, and i stopped insulin , the cat stayed free for like 8 months and when we started to increase the wet food portions sugar level started to rise again to 200 so we sticked to multiple small meals which kept glucose levels in control 70-130

after that she was considered diabetic free as long as we feeded her properly and the polydypsia and polyuria went away

the recent problem : when she turned 14 she started to drink much much more going from 300 ml to more than 600 ml daily , while all her blood glucose measurements are within normal levels 70-140 most of the time , and i used multiple glucometers, so as a physician i started to suspect that her kidneys are some what sick

i went to the vet , he took a blood sample and the test result showed normal kidney functions, a bit elevated blood sugar 250 and highly elevated liver enzymes ALT 800 and AST 200, the vet said nothing other than recommending royal canin hepatic formula

vets level here in Egypt are lame so i knew i had to do some research on my own again

i know that cat is old and may be there is nothing to do but the cat looks healthy to me and completely fine other than the polydypsia problem , she drinks a lot exceeding half a litre daily , couple of years ago she rarely visited the water bowel

have a doubt that the vet labs are not accurate and i am gonna repeat them a month later in another place , but for the time being what is your advice and opinions about the matter , the cat is fit , she is not dyspneic , eats well , plays well and definitely not jaundiced ?!

she is now on satiety royal canin since we cant find the diabetic formula any more in addition to the low carb 10-12% wet food, and both in very small amounts multiple times through the day whenever she asks, the wet food is served as a one table spoon per meal , the dry one is served in 10-15 small pieces per meal , she eats like a 7-10 times per day

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Re: elevated liver enzymes

Post by Mollycat » Thu Dec 26, 2019 12:32 pm

Mustafa I think you probably know more than most of us on the forum and I love how you are putting your knowledge as a doctor to good use for your cat's health - never mind the vets she is in very good hands with you. Just to check, have you found the normal levels for cats or are you going by human normal levels? I'm sure you are going by cat levels but just to confirm.

I don't know about Egypt but in the UK and the West generally, vets are usually contracted to one food manufacturer and recommend all their products regardless of what is really best for the cat. You mention raw, that is not necessarily always best either so don't worry.

So you have diet controlled diabetes, healthy kidneys, elevated ALT and AST, excessive thirst, good appetite (but fussy) and no weight loss. Did you check thyroid hormones? Cats are rarely hypo but hyper is common and malignancy very rare (less than 2%). Any diarrhoea, yellow or orange colour, or any blood? Pale gums?

Also some intestinal parasites can disrupt the liver, that might be worth investigating?

14 is not old, I understand what you mean but if she still feels healthy and eats and plays, maybe she is fine, but drinking a lot is certainly something to be watchful if not concerned about.

This might be helpful https://wagwalking.com/cat/condition/liver-disease

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Re: elevated liver enzymes

Post by mustafa811 » Thu Dec 26, 2019 6:04 pm

thanks molly for your kindness and reply, as to ALT and AST levels they do differ than ours a bit but the ALT level is like 8 folds increase and the AST 4 folds according to the lab test reference levels, so it is not just a slight increase

thyroid and parathyroid labs were not available at my vets clinic, so am gonna repeat the liver enzymes as soon as i find another vet lab that can do the rest of the labs, also an abdominal US

glad you mentioned the parasitic infestation part since that last visit was a messy one and she skipped her dewormer pill

well about age she doesn't seem that old indeed lol, the way she massacred the vet and his assistance the last visit, i told them upfront and they didn't believe a small sized 14 year old cat could do such a fuss, she is a lovely cute affectionate cat but only with ppl she feel safe with

there was a poor doggy outside the vets room and i swear he felt trembled from the sounds coming out of the room

anyway thanks molly for your help and i will keep you updated

merry Xmas all

edit : her gums are pinky rose and no jaundice at all, no diarrhea also but sometimes she vomits specially if she found a plastic bag to chew but i think it is not a concern since her whole family used to do this


Image81442383_722851601571120_3740087513113427968_n by mustafa811, on Flickr


ImageNans by mustafa811, on Flickr

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Kay
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Re: elevated liver enzymes

Post by Kay » Thu Dec 26, 2019 7:27 pm

can't really add much, except when I had a cat with Hyperthyroid his ALT levels were somewhere around the same, and neither my vet, nor the practice he went to for Radioactive Iodine therapy were the least bit concerned

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Re: elevated liver enzymes

Post by fjm » Thu Dec 26, 2019 9:06 pm

Thyroid would be the first thing I would look at, given how common hyperthyroidism is in older cats - especially as it is also so treatable.

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Re: elevated liver enzymes

Post by Mollycat » Fri Dec 27, 2019 8:51 am

Wow what a beautiful girl! I have always had a soft spot for the Tortoiseshells. her eyes look so bright and her coat glossy and she looks alert and healthy ... I know, looks can hide a lot, but she is stunning.

My cat's hyperthyroidism was discovered by chance. She was quite fat in spite of reduced calorie food, so no reason to suspect it, but she had a 'crash' illness with yellow diarrhoea and vomiting bile and a sudden dramatic weight loss. The vet never suspected it but because she is very difficult to take to the vets I asked for a full blood screening "while we have her here" and the tests revealed elevated ALT and bilirubin plus hyperthyroidism. The vet maintained that ALT was higher than expected for hyperthyroidism and that bilirubin was inconsistent therefore there could be an underlying liver problem. Bilirubin cleared quickly and now 9 months post radioiodine treatment her ALT is still coming down slowly. But my own research did find a link between bilirubin and hyperthyroidism, usually a hepatic portal shunt but can also happen with a gall bladder infection of some kind. This will hopefully make some sense to you! Since treatment my cat's weight has been quite normal with normal food though the yellow emissions continued for quite a long time.

Apparently elevated liver enzymes are common with elevated glucose and unbalanced electrolytes are also common. The liver lacks some metabolic pathways to deal with some toxins so diabetes can affect it ... I'm just reading from internet articles now.

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Re: elevated liver enzymes

Post by mustafa811 » Sun Jan 12, 2020 3:59 pm

well i found a vet lab couple of days ago , i asked them for thyroid profile labs and voila , she is hyperthyroid indeed

the problem now the radioactive iodine single injection is not available in Egypt for pets, the other line of treatment is carbimazole 5 mg twice daily as prescribed by the vet , i will look into this and revise the dosage myself but the thing is my cat hates oral drugs completely and to give her the pill twice daily she will probably hide and resist from now on

so any tips on oral meds administration would help tremendously

ImageIMG-20200112-WA0000 by mustafa811, on Flickr

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Re: elevated liver enzymes

Post by Kay » Sun Jan 12, 2020 5:01 pm

can you access Methimazole (Felimazole )? I administered these to my HT cat for three months before he went for radioactive iodine treatment, and they were very small, and could be split (I initially halved the amount prescribed by the vet), so I put half pieces inside soft treats (Webbox if you can get them) and fed him three pieces with the doctored one in the middle - he had over a hundred doses without suspecting a thing

I used to sit above him when offering the treats so his head was tilted back and with his mouth eagerly open, the treat naturally fell towards the back of his throat

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Re: elevated liver enzymes

Post by booktigger » Sun Jan 12, 2020 5:21 pm

Sorry to hear she is hyper-t, please do be careful about splitting tablets, there are risks to our health by doing that, and they are slow release tablets which are affected when split. I know you are a physician but I wouldn't tweak the dosage yourself without blood tests. We did have someone on here from Italy who travelled for their cats hyper-t treatment, cant remember his name offhand.

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Re: elevated liver enzymes

Post by mustafa811 » Sun Jan 12, 2020 6:21 pm

thanks all, truly appreciate your participation

i just feel a hefty burden thinking how am i gonna pill her twice daily for the rest of her life
i sure can give it to her by force but this i can do once or twice but not forever
i kinda of feel depressed i didnt even give her the 1st pill yet

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Re: elevated liver enzymes

Post by booktigger » Sun Jan 12, 2020 6:33 pm

Honestly, sometimes we have to accept that just because we can, doesn't mean we should. I've had quite a few cats where I have decided that medicating would impact too much on their quality of life and that a shorter time would be better for them. You aren't failing her if you decide that, you are putting her quality first

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Re: elevated liver enzymes

Post by fjm » Sun Jan 12, 2020 7:06 pm

There are alternatives to pilling - surgery was the preferred treatment before the radio-iodine treatment became available, and is still widely used.

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Re: elevated liver enzymes

Post by mustafa811 » Sun Jan 12, 2020 8:18 pm

yes i thought about letting her off the treatment as long as she seems happy , daily twice pills could make her live in fear the rest of her life and change her mood for the worst

anyway i sought an easy way to administer pills as a whole, and i saw that pet piller or popper , so used a large plastic pen, and emptied on the inside and used it to deliver her first pill , actually my mum administered the pill and i held the cat like a wrestler lol

hopefully this didn't take long, it was less than a minute and not that harmful, she escaped after taking the pill but i was kinda of happy she didn't left the room, i left her for like 10 minutes and went to sit down on my recliner , minutes later she came and sat on my lap :D

thanks god i consider this is a kind of success , i will buy a good pill popper that can minimize the administration time and pray that it will go easily form now on with gods will

thanks all , still open for any administration tips

about the surgery , well i think vet surgeons here lack the skills , if vets around didn't offer any help in diagnosing the cat nor treating diabetes or modalities for hyperthyroid then they definitely lack the skills , it is also an invasive procedure with general anaesthesia , lets not forget the high liver enzymes , also it has its own complications as in hypothyroid or parathyroid removal by mistake, nerve and vessels injury , also infection , so i don't really prefer this , i might had if i knew a skilled vet surgeon

ImageCat nans after her first pill lol by mustafa811, on Flickr

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Re: elevated liver enzymes

Post by booktigger » Sun Jan 12, 2020 8:24 pm

Fingers crossed it continues going that well. I use a pill popper but very mixed success over the years. If I miss the first time i resort to fingers. I think you are right not to consider surgery, it requires careful aftercare in case of calcium issues so yeah, without an experienced vet I wouldn't do it

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Re: elevated liver enzymes

Post by mustafa811 » Sun Jan 12, 2020 9:06 pm

what i liked about insulin subcutaneous injections mostly that i used the smallest 4mm needle and the cat didn't feel it at all , also small automated puncture pen when calibrated correctly the cat doesn't feel it ( for the glucometer )

wish they use such methods for administrating more meds easily

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Re: elevated liver enzymes

Post by booktigger » Sun Jan 12, 2020 9:20 pm

You have just reminded me that thyroid meds can be made into a transdermal gel that is put on the ears, not sure how easy that could be done over there though. You do have to be careful with it, my neighbour has thyroid issues and using the gel on her cat affected her levels, we used plastic spoons on the end!

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Re: elevated liver enzymes

Post by mustafa811 » Sun Jan 12, 2020 9:52 pm

Well thats a briiliant idea too, but the problem we do not have meds specially made for pets here, i must use the ones made for humans

I have a pharmacist friend, i bet he can make me that gel if i asked him

Lets see 1st what will happen this week

And since it is transdermal it can affect humans for sure, but precautions could be taken

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Re: elevated liver enzymes

Post by Mollycat » Wed Jan 15, 2020 10:50 am

You have my complete sympathy about pills, it's the reason we had I131 for my hyperthyroid girl. If travelling is possible and you have the money to do it I would definitely recommend it.

There is an ultra low iodine food, I don't know if you can get delivery to Egypt but might be worth looking into. Must be given exclusively as any other iodine source will interfere with it working. It's a pate type canned food and there is also a dry version. However both are pretty high carb so likely to be a nightmare with the diabetes.

I wonder if you could get the drugs in the correct dosage by getting a vet's prescription and ordering it direct?

Unfortunately untreated hyperthyroidism does unseen damage to the retina and heart muscle by raising blood pressure. Also the raised blood pressure can mask kidney function problems which are common in older cats.

I guess her age and your circumstances will ultimately push your decisions for her. I have a 12 year old who is basically untreatable and I know this fact could well limit her life but in the end for me their comfort and happiness and the bond we have are more important than the years clocked up. A cat knows I am well or I am unwell, or I am miserable. They don't count years. If no treatment is the right thing for her well being and your decision is to let it run and help her as you can when she needs it, then don't feel guilty - it's about what is best for her.

Oh and just to add about surgery - cats have two separate thyroid glands unlike our single twin lobed gland. Normally one is removed and in 70% of cats the other later needs to be removed. In 30% of those, there is extra thyroid material deep in the chest that can't be removed, and that is usually where the problem is. At that stage nothing can be done with surgery. Or, with both thyroid glands removed, they can go hypo, and then pills are needed. It doesn't seem a very good option really if there are others

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Re: elevated liver enzymes

Post by mustafa811 » Sun Feb 09, 2020 4:35 am

Almost a month passed since the 1st labs showing hyperthyroidism and I was going to do the reassess labs for thyroid and liver function

But just before that the cat awaken me up at 3 am vocalising in pain to find that she has a painful constipation , she was passing hard firm pellets and to pass a single pellet she goes like 4 times to the litter box

This lasted from from 3 am to 12 pm the next day (9 hours), the cat after every straining was vomiting a yellowish liquid vomit inbetween

At 1pm I took her to the vet, he said it was a simple constipation most probably due to dehydration and dry food introduction and prescribed some laxatives and excluded urine straining or megacolon

She had a similar episode of constipation 3 years ago and this was the second

So in addition to laxatives such as lactulose and magnesium hydroxide/aluminum hydroxide combination dry food was stopped for a couple of days and wet food introduced again

Anyway at around 6 pm she passed stools , also the next day she did have diarrhea so laxatives were stopped

The problem after this event the cat seemed lethargic , not purring or playing and sleeping most of the time

I am noticing she is improving with time but now a day and half passed and she is still not purring or playing like before the constipation but lethargy definitely has improved and she is eating and drinking

So is this usual and considered in recovery for the long constipation episode ?!, She vomited that day for like 10 times and strained for like a 40 times

Anyway we did the labs needed by the way and apparently the thyroid profile improved a lot but still the liver enzymes is considered high

The vet advised to lower carbimazole dosage to once daily and to add liver support medication milk thistle for like 15 days as injections every other day and rechecking liver enzymes again after that

So I am a bit concerned now about the cat physical condition after the constipation , also I disagree with the vet that only 15 days on silymarin would do a significant difference specially if we didn't diagnose what is the pathology behind her liver enzymes shooting

So I guess I will put her on silymarin syrup for a 2 months period and check later, I doubt all these multiple repetitive vets visits will do her mood any good

I feel that the cats mood now is heavily inflicted with labs , meds , injections , and vet visits and I need to give her a rest to recover

The labs results are in these links
https://flic.kr/p/2iqSNFe
https://flic.kr/p/2iqSNE2

The bilirubin is raised a bit and the platelets count is a bit on the low side

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Re: elevated liver enzymes

Post by mustafa811 » Sun Feb 09, 2020 4:59 am

Well she is definitely purring now after my last comment :D

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Re: elevated liver enzymes

Post by Mollycat » Sun Feb 09, 2020 7:22 am

Hi Mustafa, as you know yellow vomit and/or diarrhoea most likely indicate some liver issue and bilirubin being high.

I don't think the yellow is part of recovery from constipation. Diarrhoea as you know can follow constipation especially if given a significant dose of something to help ease the constipation, but yellow goes with a liver or gall bladder issue of some kind and is not normal.

She may have been lethargic and disinterested just because she was still feeling unwell, glad to see she is purring again. You have quite a challenge with limited vet access and multiple medical issues for her, thank goodness for your human medical knowledge and connections!

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Re: elevated liver enzymes

Post by booktigger » Sun Feb 09, 2020 8:53 am

While it is normal to have high liver enzymes with thyroid issues, I wonder if there is something else with her CBC being out? I note that her T4 is fine, but her T3 is high, I've never seen that on a blood test, so I don't know what that means.

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Re: elevated liver enzymes

Post by mustafa811 » Sun Feb 09, 2020 9:39 am

Hi Molly, well the yellow bile vomit was not a concern for me since it only happened after a multiple vomits with the constipation , and as I read vomiting is quite common with constipation , and as to diarrhea she doesn't suffer from it on the long run, that was one time after the laxative and it didn't concern me too since it is quite normal and a side effect to the laxative with the wet food we are giving , but inspite of all this the labs showed an elevated bilirubin level and I still don't know what is the liver pathology behind that other than diabetes and hyperthyroidism, and yes the vets here are not that good here

As to booktigger, well the labs are not fully normal but they tend to sync with the clinical condition , hb is a bit raised but it is a minimal and may be due to dehydration at the time the sample was taken

The low platelets count I don't have a proper cause for it but as long it is not manifesting as bleeding I think I shouldn't worry about it

The thyroid profile is much much better than the previous one and you can check the old one in my older comments , and both t3 and t4 are down considerably

Appreciate very much your contributions

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Re: elevated liver enzymes

Post by Mollycat » Sun Feb 09, 2020 10:06 am

Ok so I don't understand these papers fully but you probably will -

https://www.ncbi.nlm.nih.gov/pubmed/3192925

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3127041/

https://www.manhattancats.com/blog/2019 ... ns-yellow/ - this one makes me wonder if her platelet count is linked to her bilirubin levels, these things are usually connected in some way.

Thrombocytopenia - low blood platelet count. Most common cause is liver disease. Ties in with bilirubin, doesn't it?

And ..... https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6047326/

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Re: elevated liver enzymes

Post by mustafa811 » Mon Feb 10, 2020 12:18 am

A bunch of important articles molly, thanks, but since the jaundice is not pre-hepatic , so it is either hepatic or post-hepatic and ultrasonography revealed nothing , so I guess remaining investigation is to take a liver biopsy which is not present here for pets and if present I doubt I will expose her to such invasive procedure

About the thrombocytopenia, the article mentioned it might be immune related , and it is a possibility but needs further investigations

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