Initial Workup for Elevated Liver Enzymes and Decreased eGFR

Laboratory Assessment and Diagnosis

The American Society of Clinical Oncology recommends obtaining a comprehensive hepatic panel, including AST, ALT, alkaline phosphatase (ALP), GGT, total and direct bilirubin, to classify the pattern of injury 1
A hepatocellular pattern is defined by AST/ALT elevation >3× upper limit of normal (ULN) with ALP <2× ULN, according to the Journal of Clinical Oncology 1
The American Journal of Kidney Diseases suggests measuring serum creatinine and calculating eGFR using creatinine-based equations, while recognizing that in liver disease, creatinine-based eGFR overestimates true GFR 2
Obtaining urinalysis with microscopy and urine albumin-to-creatinine ratio (ACR) is recommended to assess for proteinuria and hematuria, as stated by the American Journal of Kidney Diseases 2

The American Diabetes Association recommends that metformin can be continued at eGFR ≥45 mL/min/1.73 m² without dose adjustment, but should be reduced or discontinued at lower eGFR values due to lactic acidosis risk, as reported in Diabetes Care 4
The Endocrine Society suggests that sulfonylureas, such as glipizide, require conservative dosing with caution for long-acting formulations, while glyburide should be avoided entirely, according to Endocrine Reviews 5

The Journal of Clinical Oncology recommends grading hepatic injury based on AST/ALT and bilirubin levels, with Grade 1 being mild and Grade 4 being severe 1
The American Journal of Kidney Diseases suggests staging renal function based on eGFR, with eGFR 45-59 mL/min/1.73 m² being CKD G3a and eGFR <30 mL/min/1.73 m² being CKD G4-5, and recommends monitoring and referral to nephrology as needed 2

The Journal of Hepatology recommends performing abdominal ultrasound to assess for hepatic steatosis, cirrhosis, biliary obstruction, and kidney size/cortical thickness 3
The American Journal of Kidney Diseases suggests that cross-sectional imaging (CT or MRI) should be considered if ultrasound is inadequate or if concern exists for liver metastases or structural abnormalities 2