Everything You Have Wanted to Know About You Liver
Most of us know where our heart and lungs are located in the body as well as the job they do. But not everyone knows a whole lot about the liver. It is time we corrected that. One of the organs that can be infiltrated by CLL cells is the liver. The word for a swollen liver is “hepatomegaly” and it is an indicator of advanced stage CLL. A dysfunctional liver can kill you a lot sooner than you think.
Did you know that the liver is also a gland, in fact it is the largest gland in your body? We are more familiar with thinking of lymph nodes under your chin or armpits and groin as glands. Well, liver and spleen are glands too. So, “swollen glands” or “lymphadenopathy” can apply equally well to swollen liver and swollen spleen (“splenomegaly”). Rai staging system uses liver health as one of its parameters in defining progression to Rai Stage-II CLL.
Location of the Liver
Your liver is on the right hand side of your body, just below your diaphragm. In healthy individuals it weights anywhere between 3-4 lbs. A human liver looks pretty much the same as animal livers you may eat as food, sort of a reddish brown color. I have no idea how it tastes – hey, I am a life long vegetarian and this is about as far as I go on culinary taste of animal livers.
There are two major blood vessels that bring blood and nutrients to the liver. The first is “hepatic artery” (start thinking of anything to do with the liver as “hepatic”) that comes directly from the aorta of the heart. The function of the hepatic artery is to bring oxygen rich blood from the heart.
The second blood vessel is called the “portal vein”. This brings blood directly from your GI tract. When you eat food, the job of the GI tract is to absorb nutrients from the food into the blood vessels lining the GI tract. Before this nutrient rich blood goes anywhere else, it has to be sanitized and certified safe by the liver. As you can imagine, not all the food we eat is exactly good for us – and I am not even talking about junk food. Many plant based and animal based foodstuffs have small amounts of toxic materials that can do real damage to the body. Your liver does the job of cleaning the blood coming from the portal vein. It neutralizes the toxins and the blood leaving the liver is rich in nutrients but without the toxic stuff. Think of the liver as the garbage processing center of your body, an important function that protects the rest of the body and more sensitive organs (such as heart, lungs, brain etc) and you are well on your way of understanding what the liver does.
Other Functions of the Liver
Besides getting rid of poisons, the liver does many other things as well. It is deeply involved in how we use glucose – it is responsible for maintaining appropriate levels of glycogen in your blood. Diabetic patients are quite aware that their sugar levels are influenced by the liver.
Liver is also a storage depot for trace amounts of vitamins and minerals that our bodies need for proper function. Very often we have a feast or famine situation when it comes to how much trace vitamins and minerals we consume in the food we eat. Liver stores the excess vitamins and gradually releases them into the blood as needed. Did you know that your liver makes as much as 80% of the cholesterol in your body? Cholesterol in the food we eat adds up to just 20%.
It is all too easy to poison this hard working organ and bring it down to its knees. The single biggest culprit for liver toxicity is alcohol. Believe it or not, alcohol is toxic to our body. When you down a couple of martinis, the first place that alcohol goes is to the portal vein which then heads straight to the liver for cleansing. You don’t have to be a certified alcoholic to have significant level of damage done to your liver because of alcohol toxicity. Long term drinkers suffer from liver cirrhosis, where the liver is inflamed and eventually fails to do its job well. All those toxins it can no longer handle flow unchecked to the rest of your body.
Here is the other cause that most of us do not think about: mega doses of “healthy” supplements such as vitamins, over the counter potions and stuff that interacts with each other and causes massive damage to the liver. Remember this mantra: everything you put in your mouth and swallow eventually goes to your liver. Be kind to your liver, don’t overload it with too much stuff to detox all at once.
One of the jobs the liver does is get rid of debris that accumulates when cells die due to old age or damage. For example, when red blood cells die, they release the hemoglobin that is so crucial for proper function (oxygen carrying) of red blood cells. One of the breakdown products of hemoglobin is bilirubin, a yellow colored pigment. If your liver is not functioning properly, not able to get rid of bilirubin as well as it should, this yellow material builds up in the rest of your body. Where you will see it is in your eyes and skin. “Jaundice” is easily diagnosed by even lay people because the yellow tinge of the skin and eyes is hard to miss. Jaundice is a clear indication of potential liver distress.
Liver Function Tests (LFTs)
Most of the time liver function tests involve nothing more than a simple blood test. These tests are now automated and quite cheap. If you have any concerns about your liver function, see if you can talk your GP into regular (monthly) full panel of metabolic blood tests. Different labs call this test by different names. Basically, the panel includes liver function tests, kidney function tests, levels of various electrolytes such as potassium, sodium, calcium etc, protein and sugar levels. If you want to keep track of all this information we have a nifty Excel spreadsheet where you can monitor your charts. The first page is useful for monitoring your CBC data. Third page is devoted to the metabolic panel we are discussing here.
Below is an easy cheat-sheet of the important liver functions that you should keep an eye on.
• ALT (alanine transaminase; it is also referred to as SGPT by some testing labs) is an enzyme that is present in all liver cells. When liver cells are damaged or die, this enzyme leaks into the blood where it can be detected. Normal range of ALT is between 3.9 -5.0 g/DL. Your lab will have the normal ranges spelled out in the report, as well as your level of ALT. ALT can rise very dramatically when the liver is damaged in any way, often going as high as many times the normal level. One of the major culprits of elevated ALT is acetaminophen – Tylenol. Overdose of Tylenol is a sure way of killing your liver – damage that is often irreversible.
• AST (aspartate transaminase, used to be called SGOT) is also a liver enzyme and levels can rise well above the healthy level of 10-40 IU/L if the liver is damaged. But since AST is also present in red blood cells, muscle and heart cells, elevated AST is not necessarily specific pointer of liver damage. In fact, if the AST is elevated but the ALT is well within healthy limits, this is an indication that the problem area is not the liver but something else.
• Bilirubin. As we discussed above, bilirubin results from the breakdown of red blood cells. Normally, bilirubin is captured by your liver and is excreted in your stool. (Incidentally, bilirubin is the reason why $hit is the color it is. I thought I would pass along that little bit of information). Jaundice is the clear symptom of excessive amounts of bilirubin in the blood.
• LDH(lactate dehydrogenase) is another enzyme found in many body tissues, including the liver. Elevated levels of LDH may indicate liver damage.
• Albumin is a protein made by the liver. This and total protein levels are indicators of the health of your liver since your body needs these proteins to fight infections and perform other functions. Lower than normal levels may indicate liver damage or even poor nutrition.
Specific Issues Related to CLL Patients
As I mentioned above, CLL cell infiltration of the liver is quite common in late stage disease. When your doctor pokes and prods under your diaphragm during a physical examination he is looking to see if your spleen is enlarged (left side of your body). It is a bit harder to feel an enlarged liver (on the right side and under your rib cage) and in any case there can be plenty wrong with the liver without it getting unduly enlarged. In other words, moral of the story is to get your liver function tests done on a periodic basis.
There is one more reason why CLL patients are smart to keep an eye on their livers’ health and that has to do with the many medications and drugs we take in the process of controlling the CLL.
Potent chemotherapy drugs and combinations such as FCR can overload the ability of the liver to get rid of the dead and dying cells – not just CLL cells but red blood cells and platelets etc. When red blood cells die in large numbers, not only will this be seen in dropping red blood counts but increased bilirubin levels – an indication that the liver is having a hard time getting rid of all the garbage resulting from the mayhem. When this problem rises to critical levels, the patient is said to be having tumor lysis syndrome. TLS can be potentially fatal and not something to be taken lightly.
Besides conventional therapy needed to control the CLL, many patients over-indulge in over-the-counter medications that their doctor knows nothing about. Too many pills taken without taking into account their interactions with each other can become very dangerous, very quickly. This syndrome is called “polypharmacy” and I strongly urge you to keep that in mind when you pop too many pills. The single biggest thing to worry about when you take even green tea extract capsules is the potential for liver damage. You may not be taking too much EGCG (green tea extract), but what else are you taking? Remember, you have only one liver that has to do the cleanup of all the stuff you are throwing at it. If your most recent metabolic panel tests showed elevated liver function tests, talk to your doctor about it right away. The usual protocol is to withdraw most if not all of the medications the patient is on, and after the LFTs have stabilized, gradually bring back the necessary medications.