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Treatment and the treatment process

Monitoring the liver

The liver processes many leukemia medicines. During treatment its function is checked regularly with blood tests.

Last updated: ~2 min read
On a dark navy background, a liver glows warm gold and teal as streams of light pass through and leave cleaner.
Figure 1.The liver processes medicines and cleans the blood.

01Short answer

The liver breaks down medicines, makes proteins and clotting factors, and produces bile. In leukemia treatment several things can affect it: chemotherapy (such as asparaginase, methotrexate and mercaptopurine), targeted drugs, antifungals (azoles), antibiotics, iron overload from transfusions, reactivation of viral hepatitis (B, C), and after a transplant, veno-occlusive disease or liver GVHD. So liver tests — ALT, AST, alkaline phosphatase, bilirubin, albumin and clotting — are checked before and during treatment, sometimes with an ultrasound. If results rise, the doctor may change the dose, pause treatment or switch medicines.

02Simple explanation

The body’s laboratory. The liver processes medicines.

Strain. Some medicines can irritate it.

Tests. Enzymes and bilirubin show how it is doing.

Adjustment. The plan changes if needed.

03Scientific explanation

Markers: ALT and AST reflect liver cell injury, alkaline phosphatase and GGT reflect impaired bile flow, and bilirubin reflects both; albumin and PT/INR show synthetic function.

Drug-induced injury may be hepatocellular, cholestatic or mixed. Asparaginase can cause fatty liver and raised bilirubin, mercaptopurine cholestasis, and azoles raised transaminases; transaminase monitoring is advised with several targeted drugs.

Special situations: sinusoidal obstruction syndrome (VOD) after transplant — an enlarged liver, jaundice and fluid retention; prophylaxis for HBV carriers on drugs such as rituximab because of reactivation risk; transfusion-related iron overload.

04What happens in the body?

What does the liver do?

The liver clears medicines and waste from the blood and makes bile for digestion and important blood proteins.

What do enzymes tell us?

When liver cells are irritated, enzymes leak into the blood. A rise doesn’t always mean serious damage, but it needs attention.

Small glowing particles escape from soft hexagonal liver cells into a nearby vessel.
Figure 2.Irritated cells release enzymes into the blood.

The sign of jaundice

When bilirubin rises, the skin and whites of the eyes turn yellow. Tell your team about this straight away.

A soft abstract gradient from white to a faint golden yellow, like light on porcelain.
Figure 3.Yellowing should be reported to the team straight away.

05Checking the liver

A simplified outline.

Blood tests — Enzymes and bilirubin.1Blood testsEnzymes and bilirubin.
Medicine review — Possible causes.2Medicine reviewPossible causes.
Imaging — Ultrasound if needed.3ImagingUltrasound if needed.
Repeat checks — The plan is adjusted.4Repeat checksThe plan is adjusted.
Liver protectedEarly measures.
Cause foundMedicine, infection or other.
Often temporaryAfter adjustment.

06Main liver tests

TestWhat it showsNote
ALT, ASTLiver cell injuryOften rise with medicines
Alkaline phosphatase, GGTBile flowRise in cholestasis
BilirubinBile pigmentCauses jaundice
AlbuminProtein productionAlso depends on nutrition
PT/INRClotting factorsLiver synthetic function

* Only your doctor interprets results in the context of your whole situation.

07Key terms

ALT/AST
Liver enzymes.
Bilirubin
A pigment from the breakdown of red blood cells.
Jaundice
Yellowing of the skin and whites of the eyes.
Hepatotoxicity
Harmful effect of a medicine on the liver.
VOD
Blockage of liver blood vessels after transplant.
Cholestasis
Impaired flow of bile.

08Key points

  • The liver processes many medicines.
  • Tests are checked regularly.
  • Enzyme rises are often temporary.
  • Report jaundice straight away.
  • Herbal products can strain the liver — talk to your team.
  • Alcohol adds strain during treatment.

09Frequently asked questions

My enzymes are high — will treatment stop?

Not always; often the dose is changed or monitoring continues. Your doctor decides.

Should I take supplements to protect my liver?

Not on your own: some "liver" products interact with medicines.

Why test for hepatitis B?

Some medicines can reactivate a hidden virus; prophylaxis is given if needed.

Does the liver recover?

The liver recovers well; many changes settle once the cause is removed.

10Questions for your doctor

Take these questions to your appointment. The ones you save are collected on the “My questions” page and stay on this device only.

  1. My enzymes are high — will treatment stop?

  2. Should I take supplements to protect my liver?

  3. Why test for hepatitis B?

  4. Does the liver recover?

My questions

12Sources

  1. Canadian Cancer Society. Liver problems
  2. MedlinePlus. Liver Function Tests
  3. MedlinePlus. Bilirubin Blood Test
  4. MedlinePlus. Aspartate aminotransferase (AST) blood test
  5. American Cancer Society. The Stem Cell Transplant Process
  6. Blood (American Society of Hematology), 2019. Management of acute promyelocytic leukemia: updated recommendations from an expert panel of the European LeukemiaNet
  7. Leukemia, 2020. European LeukemiaNet 2020 recommendations for treating chronic myeloid leukemia
  8. Blood (American Society of Hematology), 2017. Consensus guidelines for the diagnosis and management of patients with classic hairy cell leukemia
  9. MedlinePlus (U.S. National Library of Medicine). Uric Acid Test
  10. Cancer Research UK. Acute promyelocytic leukaemia (APL)
Medical disclaimerThis information is for educational purposes only and does not replace medical advice.
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