Continuing the blood work conversation from last week (learn more about inflammation through blood work here) - let’s dive into some typical, and some not so typical markers and patterns we use to understand liver health and function.
What does “functional” mean in blood work?
It’s important to remember that when we’re using blood work in our practice, it’s to look for these types of patterns to understand the health of your whole body system.
The second important distinction: we’re using functional ranges to compare your results against those with optimal health outcomes. Conventional ranges are set so that 95% of the testing population falls within them - that’s a lot of potentially unhealthy people we’re comparing our results to…not to mention we rarely get any real insights with conventional ranges. So often clients tell us “I’ve done blood work, but everything looks normal”, despite feeling like there’s something missing with their health. Using functional ranges, we can see so many more clues emerge and put together the patterns that are likely driving these symptoms.
Finally - the beauty of functional ranges is that it helps us “course correct” before these patterns of imbalance have the chance to progress, or put too much stress on other systems to compensate.
Ok - let’s dive into blood work as it relates to our liver!
Why is the liver important?
The liver is a central organ to several very important systems – digestion, detoxification, sex hormone balance, blood sugar, iron and other nutrient status, thyroid function, and more. THIS is why nearly every client we work with is supporting their liver – when the liver is stressed, so many systems suffer.
A stressed liver can feel like:
Having a hard time digesting fatty foods, gallbladder attacks or pain in the upper right abdomen, or prior gallbladder removal
Getting sick or hungover easily when drinking alcohol
Stinky armpits/strong smelling sweat
Adult acne
Signs of estrogen dominance like painful, heavy periods
Hypoglycemia, waking up in the night, and “hanger” if meals are delayed
Tendency towards anemia or iron overload
Symptoms of hypothyroidism like fatigue, or feeling cold all the time
Markers to look for:
So to get a fuller picture of liver health and function through blood work we look at:
Direct liver markers:
Liver enzymes (AST, ALT) and Proteins (Albumin), Bilirubin
Elevated enzymes (AST + ALT) are most commonly associated with fatty liver disease, although studies show that 55% to 79% of adults diagnosed with non-alcoholic fatty liver disease have “normal” ALT levels (by conventional standards). This is a good example of how a narrower optimal range can provide more information than traditional ranges.
Proteins, made up of albumin and globulin, are another typical element of the liver health story. Albumin is produced almost entirely in the liver, so when it is low, it’s a sign the liver is struggling to synthesize this protein - likely due to chronic infection or inflammation, liver dysfunction, or drinking too much alcohol.
Bilirubin is produced as red blood cells break down and is removed from the blood by the liver. When it’s elevated, we’re thinking about dysfunction in the liver - why isn’t the liver able to clear bilirubin from the bloodstream? This is potentially because of biliary/gallbladder issues - the gallbladder isn’t able to move bile which is filled with debris, toxins, spent hormones, and old red blood cells, aka take out the trash, so to speak.
Indirect liver markers:
Lipid panel: Cholesterol, Triglycerides, HDL, LDL
Elevated or low levels (yes, it’s possible to have LOW cholesterol - last week we learned it can be a protective compound!) in the lipid panel can indicate things going on the liver too. Cholesterol is formed in the liver and is moved to and from the liver on HDL and LDL carriers. Liver congestion or dysfunction can result in high or too low of total cholesterol, triglycerides, and LDL, and can also be a contributor to low HDL (the “good” cholesterol).
Another reminder from last week - serum cholesterol isn’t a measure of the amount of cholesterol in your diet. It is a marker of inflammation and liver stress. Our diet contributes ~25-30% of our serum cholesterol, and then our liver makes up the rest.
Blood sugar markers: Glucose, LDH
Blood sugar balance plays a HUGE role in liver health and long term liver function. For fatty liver especially, we’re thinking about balancing blood sugar first and foremost.
Glucose is a measure of your blood sugar right now. So if your fasted glucose is elevated (over 90), it’s an indicator that the liver might be under more stress. Like all tissues in the body when glucose is chronically elevated, but the liver takes on a unique role in blood sugar. It helps keep your blood glucose levels within a surprisingly narrow range (just a few teaspoons of sugar circulating at any given time).
The connections between the liver and blood sugar go hand in hand - incidents of diabetes goes up as liver function deteriorates (1), and conversely, as insulin resistance progresses to pre-diabetes, and eventually diabetes, the liver also declines (2).
LDH can be thought of as a proxy marker since it’s involved in ATP (energy!) production. When LDH is low, it can tell us glucose isn’t getting into the citric acid cycle. This can be due to hypoglycemia, or insulin resistance. Hypoglycemia is due to the liver’s inability to release stored glucose into the bloodstream when it’s needed.
When LDH is elevated, it can also tell us about a struggling liver - liver congestion, fatty liver, or biliary (gallbladder) issues (3)
Thyroid: TSH, T4 to T3 conversion
Your thyroid sets the metabolic thermostat - impacting everything from weight, to energy levels, to internal temperature, to hair + nail growth, and more.
The “liver plays an important role in thyroid hormones, as it is the most important organ in the…conversion of T4 to T3” outside of the thyroid itself (3).
A little thyroid 101 for you – TSH is a hormone from the pituitary, which is talking to the thyroid to get her to produce thyroid hormone, in the form of T4. But T4 is not all that potent, or “metabolically active” in our system. It needs to be converted into T3 to set the metabolic rate for your cells, hormones, energy production and more. But this conversion happens in the gut tissue and liver primarily. A well functioning liver is able to prioritize thyroid hormone conversion and produce proper levels of T3 to support the metabolism and cellular health.
When we see a hypothyroid pattern with elevated TSH (functionally speaking, that’s anything over 2) (4), or noticing a discrepancy in T4 to T3 levels, we’re thinking about how a compromised liver might be contributing to imbalances in thyroid hormones, and the metabolism overall.
Iron panel:
The liver is an important site for iron metabolism - aka conversion into useable forms. The liver converts serum iron (total iron) into useable a useable form, hemoglobin. Hemoglobin is an oxygen carrying compound, made up of iron (heme) and globulin (a protein also made in the liver).
When total iron is elevated, alongside other markers in this pattern, it can be a sign of liver dysfunction, and increased need for the nutrients needed to make that conversion - like B vitamins. Elevated iron can indicate the liver is struggling to convert iron into hemoglobin, and is left of circulate as total iron. Iron levels are something we keep a close eye on in our practice, because iron in excess can oxidize (similar to rusting) in your body and create lead to inflammation.
Iron markers like total iron, ferritin and red blood cell markers like hemoglobin are all part of the iron picture. Using functional ranges helps us identify these patterns or imbalances as they’re brewing and before they’ve been boiled over into something more.
These are just a handful of the markers we use to understand the full picture of liver health and function. Outside of blood work, it’s also important to take into consideration symptoms (like the signs of liver dysfunction I started with), and clues from other lab results like the GI MAP. The liver has a big role in many systems, which is why supporting the liver is a central part of many client protocols.
Cited sources
“Liver cirrhosis and diabetes: Risk factors, pathophysiology, clinical implications and management” Jan 21 2009 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2653324/
“Mechanisms of Diabetes-Induced Liver Damage” May 2016 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4868511/
“Lactate dehydrogenase production in hepatocytes is increased at an early stage of acute liver failure” Mar-Apr 2011. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3440653/
“A Study of Thyroid Dysfunction in Cirrhosis of Liver and Correlation with Severity of Liver Disease” Sep-Oct 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6166553/
“Importance of thyroid-stimulating hormone levels in liver disease” Hyun Jin Kim, Aug 18 2020. https://www.degruyter.com/document/doi/10.1515/jpem-2020-0031