Advice Please! High ALT???

Need advice..

For those that may have been following, I was scheduled back in October to have Mogee's teeth cleaned. That was put on hold.when we received his pre dental bloodwork, which showed an elevated ALT of 433. At the time Mogee was giving me high numbers and would not nadir below around 180. So the plan was to try and get him better regulated number wise and check his ALT again.

Since the first check, his numbers have gotten much better, nadir in the green nearly every day, but I noticed that he was developing small lumps along his back spine so I had him checked today.

The vet after initially checking the lumps believed them to be lipomas. We then checked his blood again and now his ALT LEVEL WAS 1846!!

Vet mentioned hepatic lipidosis and other liver related diseases but said he believed that other levels in the bloodwork would have been elevated if he had hepatic lipidosis and that he would not be eating or would be eating significantly less (None of Mogee's eating or litter habits have changed).

I was sent home with Prohepatic (pictured below) and was told to finish the bottle and in 3 weeks come back and retest. I feel it is crazy that my vet does not seem too concerned about neither the bumps nor the high ALT.

Basically, I am at a loss and any help/advice/experiences would be greatly appreciated

 

WOW that's a sky high number... I don't think I've ever seen one that high. My cat Lucky, bless him, had an ALT of 1055 when the cancer moved to his liver and started to take it over - add that to the lumps on the spine which my dog Annie had (VERY quickly and she passed of cancer) - has the vet mentioned ANYTHING about cancer?

I don't mean to alarm you, but seeing that number, hearing about the lumps... it makes me wonder. Can they biopsy one of the lumps? They could be fluid filled too, so they might be able to aspirate one of them (empty syringe stick and draw back fluid like for a blood test).

If he's eating just fine I don't think it's HL, I agree with the vet in a way that he'd have other symptoms but his liver is definitely under attack from SOMETHING. I'd either go back to the vet and ask for an ultrasound (expensive sadly) and/or biopsies or ask another vet. That's just me though! I hope others weigh in.

God love you and your baby!!

 

Exactly my thoughts with regards to cancer, that's why I initially took him in with the lumps. And I did ask about ultrasound but as mentioned he didn't seem alarmed (nor previous vet last month) about the high ALT and cancer in relation to one another.

 

PS - if this ISN'T cancer, if they can figure it out, it's probably treatable - livers regrow/heal in cats just as in humans.

 

If you think you can push past the vet's opinions go for it, if not - I'd take ALL of your paperwork, all of it... his SS, all blood test results, xrays, anything and all.. and go for a second opinion. If the lumps on the spine are benign or fluid filled, I'd feel better about your baby's liver chances. Toxins can attack it, along with other things but if they can rule out cancer usually meds and change in protein levels in the food (higher or lower) can help A LOT.

 

That is what was mentioned by my vet in regards to his liver. I've had both vets look at his bloodwork and they felt other levels would be way higher if he had cancer. He seemed to think trying the medicine may help heal the liver. But no concern over the lumps he felt and said no lumps anywhere in lymph node areas. That's why he believes they are fatty deposits. But to me they feel unmovable, almost as if attached to something.

I'm just baffled by it all. He seems completely fine, has been in the green every day at nadir nearly and is eating fine. But I know it can all change quickly.

 

Yeah he might be in the early stages though, of cancer I mean - I hate the though but can't totally rule it out. If his lymph nodes are okay that might just mean they haven't been breached yet, in some cats it's the last thing to go, in others, the first. For Lucky it was the first, sadly. Even still, fatty deposits wouldn't just suddenly sprout up like mushrooms - but oddly when it comes to lumps along the spine that's what happens, cancerous or not. Along the ribs will be next, so watch for that.

It COULD be connective tissue tumors, which would account for why they don't "move" as you palpate them - they can be cancerous or benign, and are usually linked to CT (connective tissues disorders) which in turn can SOMETIMES be linked to the liver. Hm.. *thinks*

Yeah if Mogee (love on him for me!!) was my cat, and I could afford it, I'd go for an ultrasound of the liver and a biopsy of one of the spinal lumps. Since he's primarily on Sheba which is a bit higher in fat than protein, I'd try to switch him if you can. Find a canned food with the same protein amount, there abouts, but MUCH lower fat . I'd also keep him on the Prohepatic, it's made mainly from the active ingredient in milk thistle which is what makes it so effective.

 

Adam, I'm so sorry to hear that Mogee is having issues. I was just wondering the other day how things were going for you and him. Is that all of the blood tests that they did? I'm hoping they did more complete blood work, and if so, please post the full results here. There are a few people who are really good at deciphering them. Maybe @Marje and Gracie will pop in and share her thoughts. She seems to be a rock star at it.

I read a few articles about very elevated ALT, and if there are no other symptoms, it appears that giving a supplement like your vet gave and rechecking in a a few weeks (3?) is not so crazy. I think I might ask about doing a needle biopsy on one of the lumps though, just for peace of mind.

It's good that Mogee gets below 100 during most cycles, but he still has some pretty high numbers pretty often considering how long you guys have been at this. I know that your primary concern right now is the elevated ALT and the lumps, understandably, but since issues with glucose levels can impact other things, I wanted to mention it. Have you given any consideration to trying a different insulin (Levemir, Lantus)? It would be nice to see things staying a little more leveled out for him and his spreadsheet being a little less colorful.

 

Thank you for the vote of confidence

I have a lot of experience with elevated ALT; my Gracie had a very, very mild elevation on and off. By mild, I mean she was in the 300-400s and we addressed it. It’s not just the elevated ALT that concerns me but also that the GGT is elevated. I would say hepatic lipidosis would be uncommon in a cat with an elevated GGT. I wouldn’t say it never happens but it’s rare. Typically, GGT is elevated from bile duct obstructions (by gall stones or duct inflammation), liver tumors or is secondary to pancreatic inflammation. GGT is more accurate in identifying actual liver damage than elevated ALT. An elevation in ALT can also occur if there are other organs involved such as the pancreas, intestines, gall bladder, etc. Elevated GGT is usually pretty indicative of actual liver damage.

What our vet recommended we do is have Gracie ultrasounded, which we did. Her bile duct appeared to be a little dilated and so we did a bile acid assay to be sure there was no obstruction. If there is no obstruction, ursodiol is a good medication but it cannot be used if there is an obstruction. Denamarin is a good liver support but I preferred to give milk thistle itself. Denamarin is a tablet that should be given on an empty stomach a couple hours before eating and I found it to be a challenge to give around Gracie’s eating schedule. Personally, I think there are much better liver support supplements than Prohepatic that have more milk thistle and less undesirable things in it. I got milk thistle through my vet who is also an holistic vet.

 

Thank you all for your responses. I just don't know what to do anymore. He seems fine, is eating fine and his numbers have been great.

I guess the next question is... is there something that would cause the glucose to be low? I've always heard infection etc. Causes it to be higher but Mogee has been giving me really low numbers. Is there a cancer or disease that causes the numbers to be low...like not enough sugar is produced?

His PMPs tonight was 100. He's been giving really numbers than usual. That concerns me as well.

 

Also, the vet did not think he would be able to do a needle biopsy as he said the bump was so small that he didn't think he could get any?

I don't know..

 

Back when we did the xray based on the first blood results, when the ALT was 433, the radiologist thought he may have some tiny gallstones but was not treated for them as the vet did not believe that's what they were. That was a few months ago. Would he be worse by now if they were gallstones..like sick wise (not eating etc)?

 

Not necessarily....not until they obstructed his bile duct (if they did). When I look at labs, I look for trends although I do believe that when the ALT and GGT are elevated, it’s time to do more to find out what’s going on and not just wait to retest. Needle biopsies, even ultrasound guided, can be tough to really get a good diagnostic because they have to hit the exact spot where there could potentially be malignant cells. If you got a positive on the biopsy, you could probably believe it but if you got a negative, it just means the vet might not have gotten affected cells. Again, I’d start with an ultrasound if it were me. They can tell what looks inflamed and they get a lot more info than just an X-ray.

Gracie never showed any clinical signs either.....it was routine labs when we found it but I did do labs on her every six months.

Some cancers can cause the BG to go low and consistently stay there. His SS does not bring that to mind. The ones I’ve seen have suddenly gone to green and the caregiver was fighting to keep the numbers above 50; kitty was earning one dose reduction after another. I do want to stress that not every cat that does this has cancer; we do see some cats whose liver just “snaps”, they turn solid green in the BG, race down the dosing scale, go OTJ, and are perfectly healthy.

 

Glucose levels/insulin needs can be ever changing. So, it is possible there is not anything sinister going on with that. It looks like you started a new vial of insulin just before you started getting more greens, so maybe it was fresher/stronger. Mogee's numbers are still very up and down, up and down. There are a lot of dosing changes; it seems like greens scare you, even if they are not below 50. Even if there were not quite as many changes though, it just looks to me that this insulin is not the best option for him. He needs something that will level him out more and stop the roller coaster. I got to a point with Mia where we had decent nadirs, but her pre-shots were still too high. If I tried to up the dose even a tiny bit, she would end up dropping too low. So, we were stuck. Your spreadsheet reminds me of that somewhat. Changing to Levemir changed everything. If you scroll through her spreadsheet for this year, it went from colorful Skittles to calm blues and greens (I use an AT meter so numbers are higher than they would be on a human one). The onset is later, the action is smoother. The fear associated with deciding whether to shoot or not or whether to reduce or not when a pre-shot test is low is gone. No more roller coaster, which I'm sure makes them feel bad. I'm a believer in giving an insulin a chance. We gave it 9 mos. You are 15 months in. So, just consider it.

Now, on to your more immediate concerns... I would listen to Marje and get an ultrasound ASAP. She mentioned gallstones as a possibility then you said the radiologist suspected gallstones. I would be all over checking that out. I would also be looking into milk thistle rather than the supplement, based on her recommendation.

Please let us know what you do and how things go. I wish you and Mogee the best.

 

I agree that you might want to consider an insulin change. If Levemir could work for your schedule, it’s a great insulin. Some cats see a lot of improvement but there is no guarantee. You’d just have to be prepared that onset is often about +4 instead of +2 which is what allows you to shoot lower pre shots. But nadirs can be from +8 to +12 so you’ll need to be able to test in that timeframe especially to catch the nadirs which potentially means later nights or sleep testing. We advise against making dose changes if you don’t have the data to know how low the dose is taking the kitty.....thus, be aware that those late nadir times just don’t work for some people who are working.

 

Yes, numbers started to get better once the new vial was started so I was thinking the prior vial wasn't as strong towards the end and could have contributed to the higher numbers before the new vial.

I agree that Mogee's numbers are still up and down and there are a lot of dosage changes. It is not that I am scared of the greens but during the day when I am not able to be home due to work and he gives me a low AMPS, it is hard for me to give him a dose that may send him lower as I am terrified he will go to low and I am not there to help him. I thought it was okay to do a sliding dosage scale? Especially if you have as much testing data as I do?

I guess what I was aiming for was if he was 150-200 I would give 1.5 units, 200-250 2 units, 250-300 2.5 units, and 300-350 2.75 units. And even that scale I would tweak dependent on how much he had ate for the day, how much I expected for that cycle, etc.

It is still very hard for me as sometimes PS he is so low. The past 4 PMPS' have been below 200 but the AMPS are all mid 200s. He even had a near green PMPS the other night. What would be causing him to be so low at night but higher in the morning? And the other weird thing is he usually nadirs at + 4-6 but has been dropping between +8 and PMPS lately.

When it comes to the blood work, what I posted is all that was done on December 26th. I took him in to have the bumps looked at and his vet said they were fatty deposits and that they were too small to even try to get fluid from. It worries me as he did not seem concerned at all about the bumps and that is what I brought him in for. Since he was not concerned about the bumps and since Mogee's BG has been better lately, I asked to retest the ALT levels. That is how we found out that they went from 433 to 1800+. When he saw that and talked with me about the levels, he recommended the ProHepatic to try and help heal the liver. He said he did not think that he had any type of cancer as he believed other levels in the blood work would have been high along with the ALT. He also didn't seem concerned as Mogee just had that X ray done in October.

So that is where we stand...

Obviously, I am terrified and in my mind he has cancer and not much longer to live. But he looks great, is eating normal, and seems very happy. I know that he feels the bumps as he seems to always be licking the area they are in and is always grooming himself near them. I also noticed some weird double bump along his neck, behind his ear but it almost feels different from the others as if he scratched himself. It feels more towards the surface. As for the other bumps, I was wrong, you are able to move them. They are not stationary or attached to a bone. I can move them under the skin and they are smaller than a sunflower seed and do not really have a round shape but more of an oval if even that. Really tiny.

I guess I know I can do the ultrasounds and spend $400 to tell me he has cancer but then what? I don't think that my minimum wage job is going to allow my to fight cancer. I just feel horrible. I have dedicated the last 15 months of my life to this awful disease and it is most likely going to be something else that takes my best friend from me. I have been a mess even since I found the bumps. I pray that they are just fatty deposits and his liver will magically heal but I know that is not going to be the case.

You of all know how my vet search has been here in Lincoln, NE and Mogee currently sees 2 different vets. I know many are going to say you need to find a new vet, get another opinion, etc. but I am trying my best for him. I want him to beat all of this but I do not want to see him suffer either.

I appreciate all the help but I am just at a loss as to what to do now. I have spent so much already on blood work, X rays, to only be told he is fine and that he just needs better regulated etc.

When it comes to food, it was mentioned the Sheba is too high in fat. What do you recommend that is not more expensive and is not FF or Friskies, both of which we have tried and he did not like Friskies and the FF is way too high in Phosphorus.

* He was really mad I put the tree away today

 

I'm sorry, Adam. I do understand how terrifying this is and how frustrating it is when you don't know what to do. It is also frustrating when you spend whatever it takes yet the vets really don't seem to ever know what's going on anyway.

When are you supposed to go back to have the ALT levels checked again?

 

Three weeks is when they said to have him rechecked. I wish I could do more but can't fight cancer. Praying they are right and they're just lipomas but my gut tells me otherwise

 

took my cat in for dental work and it got cancelled and i ended up going through over a thousand dollars and over 3 mths of worthless tests like the ultrasound plus stressing out my cat with different liver meds and his ALT still went from >1000 from test 7 wks earlier to 3044 and his other liver numbers all went up too by then. next step was liver biopsy and i told the vet specialist that from the beginning i told vet and you that i tought it had something to do with him having constant poop and vomiting issues in the past or maybe from getting in the sink and constantly drinking nasty water out of soaking dishes a few months earlier and that i thought he had a bacterial infection since he was showing no liver damage/disease symptoms whatsoever and you both played it off as not relevant. I then insisted she treat him with antibiotics for a bacterial infection before i agree to do a liver biopsy that may cause complications like bleeding. 3 wks later his ALT was 427 and other numbers normal, 3 wks after that his ALT was 129/normal..
Given your cat's numbers jump so much in a somewhat short time too and is showing no liver damage/disease signs, i would talk them into treating your kitty with clavamox for 3 wks, if it is a bacterial infection, his ALT numbers will go down by then for sure and then you do 3 more weeks of clavamox to make sure bacterial is killed off and ALT should be normal by then. now i am no vet mind you but, if kitty is healthy otherwise, what's the harm of doing the antibiotics for 3 wks before stressing and putting kitty through more tests like i did.

 

Thank you for letting me know your past experience. Mogee was on Amox/Clav for 2 weeks after his initial 433 ALT reading. Not sure if that is the same as clavamox? But I would think the amox/clav would have cleared up any bacterial infection but maybe I'm wrong?

 

yeah it is the same antibiotic. this type of bacterial infection takes 6 wks to totally clear so 2 wks would of just temporarily stopped it from getting worse perhaps but, not rid of it i think. sometimes it can even take 8 wks on clavamox according to vet and although not the norm, the infection can actually come right back in some cats so a recheck of enzymes after a month of stopping a full course of antibiotics is recommended. Did your kitty get his ALT rechecked within 1-2 days after stopping his 2 wks of antibiotics??

 

No he did not get it checked after those two weeks. Wish we would have looking back now.

His bumps appear to be bigger today. He just bit me trying to touch the one on his side. They are under the skin. Not sure if they hurt or he just was upset I keep trying to feel for bumps. Just fear the end is near.

 

think possitive, i think we tend to fear the worse at first when often it is not and given our kitties really can feel our emotions, it is best to be strong and think possitive for them after. hard to be sometimes though that is for sure.

i see your kitty weights 17lbs, if overweight, these lumps are actually more common in overweight cats. my 15 yr old old man mix-main coon has had a handful of fatty lumps (what i call them) for about 6 or so years, he started getting them when he was overweight for awhile and since he has lost the excess weight he hasn't gotten any new ones and ones he had i can barely feel nowadays for they have shrunk some on their own. i thought exactly like you about it at first but, vet was right on that one, they were nothing to worry about, hope that is the case for him as well.

anyhow, if the 3 wks liver med don't lower the ALT, none of the meds did with our cat. you should consider doing a full course of clavamox, my 8lb cat was on 50mg (1 ml) twice a day (100mg per day). if after 3 wks on it numbers don't go down some, then i would do the ultrasound.. if you do that, make sure to schedule the 3 wks ALT recheck a day or two before you run out of clavamox so there is no break in the 6 wks course. good luck with kitty, i hope the new year will be good to the two of you and he will be fine.

 

@Sylvie I started to mention Mogee's weight, too. I also had that thought about him being overweight and wondering if that could possibly have led to 'fatty' tumors'. That's not something I have any experience with though, but it sounds like you do.

 

He has always been a big cat. Since diagnosis he has gone from around 18 to 17 lbs.

When his ALT was 433 in October he was exactly 17 lbs. When he was weighed last Wednesday the 26th, he was exactly 17 lbs.

Would one expect him to lose some weight if he was sick with liver disease or cancer within those 3 months? I don't know. Just weird. Tonight he gets agitated when I try to feel the bumps. I know they are bothering him, at least he appears to be grooming himself where they are.

EDIT: I just rechecked vet records and back on 11/5 he was 17.6 lbs. On 12/26 he was 17 lbs.

Is losing half a pound significant here?

 

Are you sure the lumps and the high ALT/GGT are directly related? Isn't it possible the lumps are lipomas as the vet said and that something else is going on that is causing the high ALT? They may be related, but they don't necessarily have to be. Of course none of us know for sure what is going on, but rather than jump to cancer and 'the end being near', try to consider other options. It sounds like he is doing well as far as clinical signs... eating, grooming, using the litter box. Maybe in three weeks the picture will be clearer, and you will better know how to proceed. (I would ask for more comprehensive blood work, hematology and chemistry.)

I would re-read Marje's first post and give it some consideration. The fact that you said the radiologist thought there were gallstones has stuck with me. Since that is one of the things that could cause the elevated ALT/GGT, and since the vet said the other indicators are not present for some of the other possibilities, why not pursue that to see if that is in fact the problem?

As far as his weight, I had an 18lb cat who was not overweight, so weight is relative, but if he is overweight for his frame/breed, as with people, that can always factor into health issues. And, just because he was about the same weight for years and did not have lipomas does not mean the weight might not now be a contributing factor. Someone can be overweight for years before it impacts their health, so I would assume the same can be true of a cat. (I think as age gets added to weight, things take a more negative slant.) If he is, I would hope this is something the vet has brought up. Being overweight, of course, also impacts diabetes. Now, regarding the recent 1/2lb weight loss, unfortunately, like the rest of this, none of us can know for sure whether it is good or bad. If he is overweight, I would take it as a positive unless you see a steady loss that becomes concerning.

Staying positive is really important. Cats really do pick up on our stress, nervousness, worry. So, put on a happy face and wait for the longest three weeks of your life.

 

Treating FD is stressful enough on its own. I try hard not to "invite disaster" - that's the way I frame it in my mind. I focus on the here and now with Teasel and avoid revisiting his past crises as well as not dwelling on the "what ifs". @FurBabiesMama gave you great advice so deep breaths and stay as calm as you can. Get what information is reasonable and useful to get and go from there ...

I know - easier said than done but very important.

 

Hi,
Someone here asked me to weigh in. I did not read all the other members responses because I am short on time.

So it is a little strange just for one liver enzyme to be elevated. Usually if there’s a liver issue (in humans) more than 1 enzyme is elevated. If you and the vet are concerned about the liver, I would recommend an abdominal ultrasound.

As for the bumps on the back, are they soft, squishy, and easily movable under the skin? Or are they firm and fixed (not able to be moved). Soft and squishy masses are more LIKELY to be benign, or not cancerous. Hard masses are more concerning. Having said that, my 11 year old civvie has a lipoma that we are watching. It has grown in size but it’s still soft and movable so my vet recommended to do nothing. I’m keeping a close eye on it and feeling it every few days to make sure there is no change.

I hope this helps and I’m not just repeating what others have already said.

EDIT: I also just saw that GGT is also elevated. In humans, GGT is another marker of liver function. I would ask the vet what GGT shows in cats. If it’s a liver function markers in cats, I would definitely ask for a liver ultrasound.

 

I'm wondering about those bumps that you mentioned...are they in the general areas where you give insulin? I just mention it because your vet didn't seem concerned, and commented that they are lipomas, they may be injection site lipomas. I had these with my kitty, I had to move the shots around, and they got absorbed eventually. I see that you have a lot going on, sending lots of positive thoughts your way.

 

I am taking Mogee in tomorrow night to get a third opinion. When I came home from work on break today, I noticed the bumps have nearly tripled in size.

They are soft and squishy and movable. They are not at any injection sites.

I'll update after his appointment. Appreciate all the advice and information.

 

@Adam Flowers how is Mogee?

 

Mogee is doing well. I must be crazy as now 3 vets don't believe what I feel on Mogee is anything of concern when it comes to the bumps. Dr. Reif's exact words were, "I am not too sure that what I am feeling is abnormal." She seems to believe that they too, if anything, are just fatty deposits.

She also seems baffled that his ALT is sky high but that everything else with him seems fine. I brought up all that was discussed (cancer, tumors, bacterial infection, gallstones, liver biopsy, having lump biopsy, change in insulin, etc.) She said she would not be able to biopsy the "bump" as she didn't think they were big enough or that she would be able to. She said to try these new medications before doing the ultrasound.

He is now on the Prohepatic 1 pill a day, Metronidazole .5 pill twice a day, Amox/Clav 1 pill twice a day, and she also had him treated with Profender.

She seems to believe he has an infection and not tumors or masses and that obviously his liver is damaged based on the ALT and GGT. And were hoping to heal it with the medication.

We decided not to recheck the ALT at the appointment as he had only been on the Prohepatic for a week at that time. We have an appointment set for the week at the end of this month.

Right now, Mogee seems really active, happy, is eating normal and is being a champ at receiving 7 pills a day.

She said to call if I feel that the "bumps" are getting any bigger or if he stops eating, etc. She did say that she cannot rule out anything sever but that she feels that the steps we are taking now is what she feels is best at the moment.

So I guess I just keep watching him, give him all these pills, and pray it works. Obviously the next step if the ALT does not change is the ultrasound and go from there.

I appreciate all the help and advice and we are both just going day by day.

 

I was thinking about you and Mogee the last couple of days. So glad to hear he is feeling good and hopefully your stress over some of this is reduced after this last vet visit. Hoping he is on the road to recovery with the medication that can get his liver numbers looking better.

I watched your video on BG testing a while back and was impressed with what a good boy he was for testing. Sounds like he is taking his medicine like a good boy too, good kitty

 

Thank you for the kind words and yes, he is such a good boy. It sure makes things a ton easier.

This was him last night taking one of his pills..


Just praying the medication works. Heading out now to get a probiotic as he just had really bad diarrhea.

 

What a good boy!

 

I'm so glad he is doing well. Cute video. I love that boy!

 

@Adam Flowers don't you have a vet appointment this week?? Please let us know how Mogee is doing.