High ALT levels, treatment is not helping, what to do?

Hi,

this is my first post here. I've been reading this forum since our cat started having liver issues and found lots of very helpful information. I hope you can help us. Our cat is 10 years old (brown tabby). Up until last year, we were feeding her Science Diet dry food and had no issues. Last year's blood test was normal. Then I tried to switch her to mature cat diet, and it didn't go well. I probably tried 4-5 different brands of dry food and we finally settled on Royal Canine for mature cats. We also give her I Love My Cat wet food from Costco. But since then, she's been very finicky with food. More recently, she started throwing up often, sometimes daily. She has lost a lot of weight as well.

We took her to a vet and the blood tests showed elevated liver enzymes. ALT was at 374. Based on her lab results and ultrasound, the vet diagnosed her with inflammatory cholangiohepatitis with bilary hyperplasia.

The vet recommended denamarin (one 90mg tablet daily for 30 days), prednisolone (1/2 ml twice daily) and ursodiol (1/4ml daily). We have been giving her these meds for 3 weeks now. Since she wouldn't eat dry food at all, we've been feeding her boiled chicken and canned food. Her appetite is back and she doesn't throw up anymore. Her weight is increasing and she has gained close to a pound since we started the meds. We were very encouraged because she was acting absolutely normal. We took her for a blood test yesterday, and the resutls were unexpected. Her ALT level increased to 1172! It was at 374 3 weeks ago. The vet was surprised as well but recommended continuing with her meds and come back in 3 weeks for another blood test. The cat has been having upset stomach since we began the meds. We were told that it's a common side effect.

What do you think? Any ideas what could increase the ALT level so dramatically? Does the treatment seem reasonable? The vet did mention that ursodiol is definitely working because other blood test values improved. I could check what exactly it is, if important.

I'll be grateful for any feedback. Thank you.

I had a kitty that had cholangiohepatitis along with fatty liver and his ALT did the same thing.  It kept increasing while he wouldn't eat, he was on a feeding tube.  He then started eating well on his own and his ALT continued to rise.  You are really doing all you can do medicine wise and denamarin is a very good supplement to help the liver heal.

It's really good that he is only eating wet food.  Along with the other benefits it is also more easily digested.  Since you have been looking through threads you have probably seen this link http://catinfo.org   It is a really good and comprehensive article on feline nutrition.

Has your kitty had a pancreatitis test ran?  Often times Cholangiohepatitis accompanies pancreatitis. 

It has the same link with IBD.  I think inflammation in any part of the digestive system spreads easily to other parts.  I had a vet diagnose Patches as having pancreatitis,  The next vet tested him and he didn't have it.

I am becoming more and more suspicious of the pancreatitis diagnosis.  The lab test for it has been around and routinely used for a number of years now and all the sudden there are all these kitties coming up with pancreatitis.  I know Patches was misdiagnosed with it because he had IBD with unusual symptoms.

I don't think we ran a pancreatitis test. I'll ask the vet about it.

Denice,
Did your cat's ALT levels go down eventually? What happened?

They finally came down.  When they started coming down they dropped really fast.  That was 3 years ago and he is still fine.  He is on a steroid for IBD and the vet checks his liver enzyme levels every six months.
 

Well, I have a discouraging update on our kitty. We just got back our blood test results and they are not good. ALT level is 1700, which is a significant increase over the past 3 weeks. She is still on the same meds and we have been diligent about giving them to her. The strangest thing is that clinically she is doing great: eating well, gaining weight, playful and active. I just can't understand how it is possible.

We have been referred to an internalist because our primary vet is out of options. I do hope they will figure out what's going on.

If anyone had a similar experience with their kitty, please let me know. I'm very worried.

Mak17f, in my reply to your pm I forgot to mention Cecil was also on denamarin and prednisolone as well as the metrodiazole (again not sure I spelled it correctly) but not ursodiol.

I hope they do get it figured out.  My kitty had high ALT but the cause was known.  It is odd that she is still eating and acting normally.

Sounds like Fatty liver to me, given what brought her to this situation.
How are the other liver enzymes numbers? If only the ALT is high, you have much less to worry about...

Keep this kitty eating and keep going..... This will be THE MOST IMPORTANT THING for her :nod:
And as my vet always says, which I totally agree with him, there are many times that we need to "treat the kitty and not the numbers"
PS - your post doesn't sound discouraging to me at all..... It would be if she was acting sick and lethargic..... Keep going and those numbers are going to come down.
If I were you, I would put her in the cleanest wet diet you can find, remove her from dry IF SHE EATS READLY - if she doesn't don't change a thing - the most important thing is for her to eat.
If she is taking ANY medicine: Medication can affect ALT as well - pred, antibiotics, are some classics on that matter - talk to the vet about discontinuing all meds and going completely natural.
Basically, you want to remove all toxins from her body and let her liver rest......
Edit: I see she is eating only wet and chicken. What exactly are you feeding her? Be aware of the chicken - Not for anything, but if you are feeding more than 15% of the diet on a long term, you should balance that with calcium and organs. So keep the chicken, cooked or raw less than 15% of what you feed in canned (I am not against chicken, I actually feed my crew home-made raw and they do wonderful! )

Thank you everyone for the feedback! This is what the latest blood test showed:

1/28/14                        

ALT 1738

AST 557

ALKP 191

The blood test from 3 weeks ago had the following:

1/7/14

ALT 1172

AST 387

ALKP 255

The blood test from 7 weeks ago had the following:

12/5/13

ALT 340

AST 91

ALKP 173

Shortly after this first test, the vet put her on her meds: prednisolone, ursodiol and denamarin. So, she's been on it for almost 1.5 months now and the liver results keep getting worse. There were some things that have improved, so the meds are doing something but not for liver.

She is eating everything now. Her appetite is better than I ever remember but I suspect it's because of the meds. We give her a can of wet food a day ( Kirkland "I love my cat") and dry Royal Canin mature cat ( 2-3 oz). We don't give her boiled chicken anymore. If we give her more than one can of wet food a day, she has upset stomach. This balance of dry/wet seems to work the best.

I'm going to research this metrodiazole ( sp?) medicine. We are going to an internist tomorrow and hopefully, they will figure out what's going on.

Once again, thank you for your feedback and support!

Good that the ALKP is getting lower, that's good news...
The pred is probably helping with her appetite, and reducing the inflammation, so while it can elevate the ALT, you need to be careful when taking her off of it... Talk to your vet about the benefits vs the REAL need, and no matter what you do, do it very slowly...
The most important thing is for her to eat well, and if she continues to do so, chances are those numbers will fall back into place :cross:
It takes time for those numbers to go back to normal- with my cat, which was not nearly as high, it took at least six months.
As long as he was doing well, we monitored every 2 weeks, then monthly, then after three months, then every six months.
A crucial thing for him was to be kept off all meds - not supplements like denmarin and probiotics, but his vet immediately took him off Metronidazole and prednisolone. Because of that I avoid giving him meds unless absolutely necessary... But Bugsy's issue wasn't this disease, was chemically induced elevated ALT.
I know cats are all individuals... So this is just my experience... I do think though you have much to look up to, since she feels fine and she is eating. I do think it will take time and it does, but she will be fine
Has your vet discussed giving her fluids?

When my kitty had fatty liver he started eating well and his ALT continued to rise.  We knew that he had fatty liver but the vet was surprised by the continued dramatic rise in his ALT.  When it started to drop it dropped really fast.  That was 3 years ago and he still has a liver panel done every 6 months.

Denice,
For how long was your kitty on meds before the ALT levels started dropping?

Caroline,
Thank you for your advice. I had no idea that prednisolone could increase ALT levels. I will ask the vet about it. We were warned that it would take a long time to wean her off prednisolone.

One more question.... We have a 10 day vacation planned in a month. Can't cancel it at this point. What should I do about the kitty and her meds? Previously, we asked our neighbors to check on her every few days. I can't ask them this time as it's a lot of responsibility to commit to checking on her and giving her meds 2x day. I don't want to take her to a kitty inn or something like that because of her age. What would you do in my position? Any services you could recommend? We are in SFBA.

Actually he is still on a steroid, the dosage was cut back to a maintenance dose.  He has IBD which caused him to quit eating and the vomiting which then caused the fatty liver.  His took maybe two weeks after he started eating again before his ALT came down.  Once it started dropping it dropped really fast.  I don't know what you were thinking in terms of cost or how much it is there but we have people here with petsitting and dogwalking businesses.  They will come in and take care of feeding, litterboxes, and meds.  I don't know exactly what the going rate is but I think it runs around 10 to 15 dollars a day.  They only charge extra if the meds are by injection.

mak17f said:

Denice,
For how long was your kitty on meds before the ALT levels started dropping?

Caroline,
Thank you for your advice. I had no idea that prednisolone could increase ALT levels. I will ask the vet about it. We were warned that it would take a long time to wean her off prednisolone.

One more question.... We have a 10 day vacation planned in a month. Can't cancel it at this point. What should I do about the kitty and her meds? Previously, we asked our neighbors to check on her every few days. I can't ask them this time as it's a lot of responsibility to commit to checking on her and giving her meds 2x day. I don't want to take her to a kitty inn or something like that because of her age. What would you do in my position? Any services you could recommend? We are in SFBA.

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I will be 100% honest with you.... I would cancel my vacation.
If you put her in a pet hotel, she won't eat... That's a death sentence. Forget about getting someone to check on her every few days (IMHO that's never a safe thing to do...)...
I have a live-in pet sitter stay here when I travel, and trust me, I travel A LOT. it is not cheap, but IMHO it is the safest route to go..... Besides you staying over. And dont you think boarding at the vets are any safer I have seen plenty of kitties get worst from fatty liver or even doe when left at the vet....

I don't have any advice to give.. but my kitty is currently at the emergency hospital because of high alt levels and fatty liver, just wanted to let you know that we're all thinking of you and hoping your kitty pulls through okay!!

Thank you all for the support! We went to an internist yesterday. She said it was most likely chronic hepatitis or lymphoma. It was her educated guess based on the tests we've done so far. She also said that the ALT levels should have come down by now ( after 1.5 months of meds). She suggested doing an ultrasound-guided biopsy to find out for sure. We previously had a needle biopsy done but it was negative for lymphoma or fat liver decease. We thought long and hard about all the pros/cons of this procedure. Our kitty is 10 years old. We decided to do it to find out for sure. The doctor said that the recovery is fast after the procedure and it's not very traumatic. The biopsy is next week. I'll keep you posted.

 If you had this procedure done on your kitty, could you please share the experience?

Carolina,

we can't cancel our vacation. If I had any flexibility, I would have canceled it. I think we are going to hire a professional pet sitter or ask around the vet clinic if any of the nurses would be willing to check on her daily and administer her meds.

If there are any folks here from the Bay Area and used similar services, please let me know.

Sparkie,

so sorry to hear about your kitty. I wish your baby a speedy recovery!

Here's a quick update on our kitty. The doctor diagnosed her with advanced liver fibrosis. She will be on 5 meds: prednisolone, ursodial, denamarin, vitamin E and colchicine forever. Apparently, there's nothing else we can do. We should expect a significant decline in her condition within a year.....I can't believe it. I totally expected her to live for 20 years.

The ultrasound- guided biopsy wasn't a big deal at all ( except for the cost). The kitty was back home the same day and didn't seem to have any issues at all. I'm glad we did it.

Thank you everybody for your helpful feedback.

Oh no!  I am so very sorry for this diagnosis.  I just learned my 7 year old boy probably isn't going to make it to be 20 either.  Major bummer.  Sending good vibes for your kitty.  Denamarin is really good for liver healing.