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Tips, trends, and best practices shared by our team of life insurance underwriters and technologists

Underwriter’s Guide to Measuring Liver Function [A Sing-A-long]


Part II of our Underwriting Liver Function Blog Series:

Remember when the movie Sound of Music taught us ‘when you read you begin with A-B-C and when you sing you begin with Do-Re-Mi’? Even if you haven’t seen the movie I am sure you remember using the ABC song to learn the alphabet. The moral of the story is that songs were and are used to make learning key concepts easier. I figured, why not find out if singing a song (even if it’s in your head) can help underwriters remember key tests to conduct when underwriting liver function. Sounds a little crazy I know, but you’ll be singing along with me in no time!

In the words of Maria, let’s start at the very beginning, a very good place to start. AKA let’s review what we learned in Part I of this liver function series. I answered the age-old question, does my doctor know how much I really drink? And introduced liver enzyme function as the first place underwriters should look to understand liver function.

Now who is ready to sing? And of course learn about other tests underwriters should be aware of when testing liver function.

Albumin [True Colors – Cyndi Lauper]

You with the underwriting eyes don’t be discouraged….Albumin (one of the plasma proteins) is said to be one of the truest measures of liver function. Serum albumin, the globular protein responsible for regulating oncotic pressure in the blood volume, is produced by the liver. When you see low serum albumin on a blood test, it stands to reason that the liver is having difficulty producing adequate quantity, ergo there is a liver impairment. There are a small number of other causes, such as nephrotic syndrome (in which case the problem lies not in albumin production but in albumin loss) or late-stage pregnancy, but regardless, low serum albumin is never a test that you want to leave unexplained. In other words, you need to see the true colors (see what I did there?)

Globulins [It’s not right, but it’s okay – Whitney Houston]

Globulins make up the other half of protein in the blood, and are produced by both the liver and the immune system. For these, we are concerned mainly with elevated counts, which are most often indicative of infection, but in other cases can point to something insidious. Therefore, elevated counts may not look right BUT it could be okay (thanks Whitney!). As usual, watch for elevations in globulin that are associated with other abnormalities. For instance, a low serum albumin combined with an elevated globulin is a classic marker for alcohol abuse.

Bilirubin [Mellow Yellow – Donovan]

‘They’ call me (bilirubin) mellow yellow…. because it is perhaps most commonly known for producing that “yellow” skin tone seen in cases of jaundice. Bilirubin is a product of the breakdown of red blood cells. Serious elevations can be caused by liver diseases or blockages in the bile duct. More innocent elevations in bilirubin can be brought about by just fasting, or the benign, genetic disorder Gilbert’s syndrome.

As an underwriter, it is important to ascertain whether a bilirubin elevation is something we need to be concerned with, or something that is probably harmless. Mild elevations in an otherwise normal blood profile is rarely anything to worry about, but elevations in combination with other abnormal liver function tests need to be correlated clinically.

High-Density Lipoprotein [Don’t you, forget about me – Simple Minds]

Anyone else picture the scene in Breakfast Club when they hear this song? Well now you can also picture High-Density Lipoprotein (HDL-C) which is also known as your ‘good’ cholesterol. High concentrations of this molecule are generally seen as favorable since they lower the risk of stroke and heart attack. So why is it on this list? Highly elevated levels of HDL-C can be associated with sustained, *possibly* excessive alcohol intake. Now, don’t suddenly assume that every client you see who has an elevated HDL-C is a boozer. Remember in my previous blog, I said to watch for patterns. An elevated HDL-C in the context of an otherwise normal blood profile? Not really a concern. But what about with a spiking GGT, and/or an elevated AST over ALT? Now the pieces begin to fit together.

Carbohydrate-deficient transferrin  and Hemoglobin-associated acetaldehyde [Hips Don’t Lie – Shakira]

Or in this case, CDT and HAA don’t lie because they are known as alcohol markers. While a BAC test examines a patient’s blood alcohol at the time of testing, CDT and HAA tests were designed to spot excessive alcohol users (even if they haven’t consumed alcohol at the time of testing). For example, even if a usually heavy drinker stops drinking for two days in advance of their insurance lab test, CDT and HAA can still paint a picture of the individuals’ regular drinking habits for an underwriter. This was, at least, the theory and aim behind these tests.

Hemoglobin-associated acetaldehyde

Or HAA, is now all but a relic of insurance lab testing. Perhaps a few companies still use it nowadays, but HAA’s high-sensitivity, low-specificity features don’t make for a very reliable report. Be very wary of false positives here – and maybe ask yourself, why am I still paying for this test?

Carbohydrate-deficient transferrin

Or CDT, is not impeccable itself but is far more reliable than the above. CDT is highly-specific, but suffers from somewhat lower sensitivity, such that a client would need to be consuming at least 5 drinks every day for at least 2 weeks before elevations would be seen. This makes it good reflex test to get when you see patterns in liver enzyme elevations that suggest alcohol overuse; however, a negative test result is not necessarily indemnifying moderate alcohol intake – so watch out for false negatives here. The test is also not sensitive to binge-drinking.


Time for an intermission before we continue with our sing-a-long, in part III of our Underwriting Liver Function Blog Series.  

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Written by: Elliott Dickson

Elliot is Lead Underwriting Consultant at RGAX, supporting the RGAX Underwriting Solution Services team. He leads consulting projects, offering his expertise to advise clients on underwriting best practices and supporting them as they define and implement solutions. Elliott supports production underwriting and continuously mentors RGAX underwriters with guidance on technical and business inquiries. A graduate from University of Toronto, Elliott holds degrees in both the life sciences and philosophy.