Liver Function Testing: How Significant Of A Problem?

Insurance blood testing inevitably contains liver function testing, and just as inevitably will reveal abnormalities out of the normal range. In fact one in five or six sets of tests may show values above normal. Sometimes the results are abnormal enough to spur further testing and reveal significant health problems. Other times they have little if any mortality significance or may already be accounted for in an insured’s list of health conditions. Identifying which conditions have at most mild consequences in evaluating mortality help insurers separate uninsurable or highly rated risks from those which can be often taken as applied for.

Liver chemistry tests include alanine transaminase (ALT) and aspartate transaminase (AST). They may also be known as SGOT and SGPT respectively. Not every lab references the same normal range for these tests—some use 30 U/L, other use 45 U/L. It’s important to look at the reference ranges provided for each test to see what values fall into each’s lab normal range. The American College of Gastroenterology segregates rise in LFTs (liver function tests) as mild, moderate and severe. Less than two times the normal range classifies as mild, while 10-15 times normal is severe. Mild increases can be associated with severe disease, so putting a picture together of overall health is essential. But mild increases can also be classified as standard medical risks, and those are the ones that are most insurable.

The most common cause of mildly elevated liver function testing is metabolic dysfunction, sometimes known as fatty liver disease. These are most typically represented by mild (or normal) AST levels and elevated ALT levels. Overweight individuals, those with Type 2 diabetes and those with metabolic syndrome most fit this profile. Physicians rarely work these cases up in clinical practice unless the values are significantly abnormal, and ultrasound and the use of fibrosis scores are the most common further testing that is used. Those whose build or diabetes control is already factored into a mortality assessment don’t need additional ratings for these testing elevations. Loss of weight, better diabetes control, exercise and medication are the usual treatments, and good risk factor control more often than not mitigates any risk represented by small LFT elevation.

An opposite pattern occurs in a condition that represents more serious overall mortality—alcohol induced liver disease. Alcohol excess isn’t often admitted by a client, and even an APS may underestimate the problem when the doctor relies on the patient’s self-reporting of alcohol use. In these situations, the opposite ratio is exposed—AST is higher than ALT, usually in a ratio of 2:1 or more. Other associated lab testing increases the suspicion of alcohol over-use—A GGTP is often elevated, HDL is higher than would be expected and certain parameters on a CBC may be suspicious. Insurers now routinely get CDT (carbohydrate deficient transferrin) as reflex testing when LFTs are elevated or fit this pattern, and this test has been shown to be quite specific for alcohol abuse. It’s a difficult situation when an agent or broker tries to broach alcohol as a cause for rating or decline with a client in denial, but the testing usually speaks for itself. Cessation of alcohol usually returns all testing to normal unless the abuse has been chronic over years and is causing liver injury.

Chronic hepatitis (both B and C) are notable causes for liver function abnormalities, hepatitis C now overtaking hepatitis B in frequency in part because of the hepatitis B vaccine now required of school age children. Often considered uninsurable years ago (especially hepatitis C), antiviral treatment has helped to arrest the virus and liver function is preserved in many under treatment. Insurers may screen for hepatitis B and C as a reflex test when certain parameters are met, but in those under treatment whose current viral loads are absent and under treatment mild LFT abnormalities may persist. These are accounted for and a good percentage are insurable at standard or close to standard rates.

There are many other causes for mild liver function abnormalities, including thyroid disease, Wilson’s disease, autoimmune hepatitis and other viral infections. Two others are worth discussion: Hemochromatosis and drug induced liver abnormalities. Hereditary hemochromatosis is a condition where there is hepcidin deficiency, resulting in iron overload in the liver. Further testing illustrates the condition, and treatment by phlebotomy keeps the condition in check. Drug induced liver function abnormalities is also a restively common cause of an increase in LFTs. This is not so much drugs of abuse but often commonly ones used for other medical conditions, such as atorvastatin (Lipitor) or other statin drugs used to lower cholesterol. Stains are metabolized in the liver and the ALT elevations are thought to be the result of a toxic intermediate of drug metabolism. Stopping the medication reverses the test abnormality, but many doctors will choose to continue the statin if the LFT elevations are mild, and the medication has a beneficial effect on cholesterol as a risk factor. These elevations are minor and generally don’t figure into any kind of rating once the cause is identified.

Elevations in liver function testing are in a large majority of applicants unknown to anyone (even their primary care physician) and asymptomatic, resulting in an unwelcome surprise in risk evaluations. Mild elevations with a known cause however are very often no cause for alarm and can result in standard or as applied for insurance applications.

MD, FACE, FLMI, board certified internist and endocrinologist, is medical director for SBLI of Massachusetts. He has extensive brokerage and life insurance experience over 30 years with Pacific Life, MetLife Brokerage and Transamerica Occidental Life.

Goldstone is board certified in insurance medicine and the inaugural recipient of the W. John Elder Award for Insurance Medicine Journalism Excellence. He was also honored as a fellow of the prestigious American College of Endocrinology and has written monthly for Broker World from 1991 to September, 2021.

Goldstone can be reached by ­telephone at 949-943-2310. Emaill: [email protected].