Case report: Why we need better liver disease biomarkers

Monty: A case highlighting the poor sensitivity of ALT as a marker of liver disease in histologically confirmed chronic hepatopathy.

A 4 year old Male neutered cocker spaniel was presented to the R(D)SVS Internal Medicine Service for investigation of abdominal swelling 2 weeks duration.

  • Clinical examination: No abnormalities other than ascites on abdominal palpation
  • Clinical pathology: Haematology unremarkable, urinalysis, unremarkable, ALT normal, hypoalbuminaemia, elevated ALKP and bile acids
Monty Reference Range
ALT IU/l 52 21-102
ALKP IU/l 116 * 20-60
Bile acids μmol/l 26.0 * 0.7.0
Bilirubin μmol/l 0.1 0-6.8
Creatinine μmol/l 73 40-132
Albumin g/l 18.1 * * 26-35
Globulin g/l 25.5 18-37

Ultrasound: No abnormalities detected other than excess free fluid and an increase in size of the caudal vena cava as it approached the liver hilus with reduced blood flow.

CT: findings reflected ultrasonography
Major problems

  • Ascites
  • Hypoalbuminemia
  • Constriction of intrahepatic caudal vena cava

Recommendation following ultrasound and CT was surgical exploration and liver biopsy.

Healthy liver biopsy (L) Monty (R)
Chronic hepatopathy

This case highlights the challenges of non-invasive diagnostic assessment of liver disease.

A wide range of markers are historically evaluated with variable sensitivity and specificity

  • ALT is widely considered the best available marker for liver disease
  • There is increasing evidence of variable suboptimal sensitivity
  • The fact ALT was normal in Monty’s case despite dramatic liver pathology highlights the need for novel biomarkers with better sensitivity and specificity for liver disease diagnosis