The liver is the largest internal organ and is responsible for some 500 bodily functions. It processes almost everything we ingest, breathe, or absorb through the skin. It plays an important role in digestion and metabolism, regulating the production, storage, and release of sugar, fats, and cholesterol. The liver produces a variety of important proteins, including enzymes, hormones, blood proteins, clotting factors, and immune factors. Finally, the liver plays a role in detoxification. It filters infectious organisms, alcohol, heavy metals, drugs, and other poisons from the blood, and also processes and eliminates toxic byproducts of normal metabolism.

Liver Damage

Because the liver performs so many vital functions, liver damage can impact almost all body systems. As the liver sustains damage, normal tissue can become fibrous (fibrosis), fatty (steatosis), and scarred (cirrhosis). Symptoms of liver disease may include fatigue, loss of appetite, nausea, vomiting, abdominal pain, and jaundice (yellowing of the skin and whites of the eyes). When the liver becomes too heavily damaged, it can no longer carry out its normal functions, a condition known as decompensated cirrhosis. Scar tissue may block the normal flow of blood through the liver, causing stretched and weakened blood vessels in the esophagus and stomach and internal bleeding. Reduced production of blood proteins may lead to fluid accumulation in the abdomen and easy bleeding or bruising. Inability to process metabolic byproducts may lead to a buildup of bilirubin, causing jaundice, and other toxins such as ammonia, potentially leading to impaired brain function or even coma.

Liver Monitoring

If you have hepatitis, you should be monitored regularly to determine the extent of liver damage, whether treatment is indicated, and how well treatment is working. Regular liver function tests are also important if you are taking antiretroviral regimens for HIV in order to detect liver damage that may occur as a drug side effect.

Liver damage may be indicated by high levels of liver enzymes including alanine transaminase (ALT, normal level 0-48 IU/L), aspartate transaminase (AST, normal level 0-42 IU/L), alkaline phosphatase (AP, normal level 35-125 IU/L), and gamma-glutamyl transpeptidase (GGT, normal level 30-60 IU/L). Other liver function tests include bilirubin (normal level 0-1.3 mg), albumin (normal level 3.2-5.0g), and prothrombin time (a measure of blood clotting). Abnormal liver function tests do not always indicate liver damage. You could have high liver enzyme levels but little or no liver damage, or normal liver enzyme levels despite serious damage. A liver biopsy is a better tool for determining the extent of liver damage. A high level of alpha-fetoprotein (AFP) may -- but does not always -- indicate the presence of hepatocellular carcinoma (HCC), a type of liver cancer that occurs more often in people with cirrhosis. If you are being treated for hepatitis B or C -- or HIV -- your blood cell count should be monitored regularly, since low counts can be a side effect of many drugs.

Maintaining Liver Health

Whether or not you have existing liver diseases, you can take several steps to keep your liver healthy. These include getting regular medical care; avoiding alcohol, recreational drugs, and toxic substances; eating a healthy diet; engaging in moderate exercise; and taking measures to manage stress and fatigue.

Alcohol, Drugs, and Toxins

Heavy alcohol consumption can cause liver damage on its own, and is known to speed up liver disease progression in people with hepatitis B or C. It is not yet known whether light or moderate alcohol consumption is harmful to the liver. Many experts recommend that if you have hepatitis -- and especially cirrhosis -- you should not drink alcohol at all.

Certain prescription and over-the-counter medications, recreational drugs, herbal remedies, and vitamin and mineral supplements can be toxic to the liver (hepatotoxic), especially when taken in high doses or used in combination. Drug toxicity is more likely if you have existing liver disease. A damaged liver may have more difficulty processing medications, potentially leading to more serious drug side effects. Several anti-HIV drugs -- in particular some of the protease inhibitors and non-nucleosides -- are associated with increased liver enzyme levels and other signs of liver toxicity. Be sure to tell your healthcare providers about all drugs, herbs, and supplements you are using so they can be on the lookout for possible drug interactions.

Because the liver processes toxins, it is important to avoid substances that may harm the liver. Avoid exposure to toxic liquids and fumes including solvents, paint thinners, and pesticides. If it is necessary to use such chemicals, work in a well-ventilated area, cover your skin, and wear gloves and a protective face mask.

Diet and Exercise

A healthy, well-balanced diet is important for all people, with or without hepatitis or HIV disease. Such a diet is low in fat, cholesterol, and sodium, high in complex carbohydrates, and has adequate protein. Drinking enough fluid is also important -- eight glasses of water per day is often suggested. Many experts recommend that people with liver damage avoid raw or undercooked shellfish (which may contain infectious organisms or toxins), processed or preserved foods (which may contain chemical additives), fruits and vegetables treated with pesticides, caffeine, and chocolate. High doses of vitamin A, vitamin D, iron, and niacin can be toxic to the liver. In some cases, people with advanced cirrhosis may be advised to limit their consumption of protein. Many people with hepatitis -- as well as those with HIV disease -- experience loss of appetite, nausea, vomiting, and diarrhea, sometimes as side effects of drugs. It may be helpful to eat small, frequent meals or snacks rather than three large meals each day, and to avoid spicy or fatty foods.

Regular aerobic exercise can improve overall fitness and may help reduce fatigue, stress, and depression. Most people with liver disease can safely engage in moderate exercise, but strenuous exercise may lead to a flare-up of symptoms. People with advanced cirrhosis should be cautious about exercising. If you have hepatitis or HIV disease, consult your healthcare provider before starting an exercise program.

Alternative and Complementary Therapies

In addition to pharmaceutical drugs, many people use alternative and complementary therapies for hepatitis. Some find that a combination of conventional and alternative modalities is more effective than any single type of treatment. Herbs often suggested for chronic hepatitis B or C include milk thistle (silymarin), licorice root (glycyrrhizin), bupleurum, phyllanthus, and schisandra. Herbal remedies should be treated like drugs, since they may have side effects and can interact with conventional medications. Many herbs can be toxic to the liver, including chaparral, germander, kava kava, pennyroyal oil, and plants that contain pyrrolizidine alkaloids. Nutritional supplements suggested for hepatitis include vitamin C, vitamin E, selenium, glutathione, N-acetyl-cysteine, alpha lipoic acid, bile acids, coenzyme Q10, lecithin, s-adenosylmethionine (SAM-e), and thymic factors. Some people report that acupuncture helps relieve their symptoms and improve their overall sense of well-being. Inform all your healthcare providers about any herbs, supplements, or other alternative therapies you are using.

Hepatitis A and B Vaccines

Hepatitis A and hepatitis B can be more severe in immunocompromised people and in people with existing liver damage. Most experts recommend that if you have HIV or hepatitis C, you should receive vaccines to prevent these diseases if you haven't already had them. Today, children in the U.S. routinely receive the hepatitis B vaccine as infants or teenagers. A combination hepatitis A/hepatitis B vaccine is available. There is no vaccine for hepatitis C yet.

General Wellness

Living with a chronic disease can be stressful, and fatigue is a problem for many people with hepatitis or with HIV disease. Stress management, good time management, and measures to reduce fatigue can help improve your quality of life. Be aware of your limits and try not to overexert yourself. Alternate strenuous activities with more restful ones. Take naps as needed and get an adequate amount of sleep at night. Many people find it helpful to use a daily planner to make activity schedules. Meditation -- a method of relaxation and clearing and focusing the mind -- may also help reduce stress. Therapy with a psychologist or social worker may be beneficial, and peer support groups can offer a safe space to discuss emotional issues and develop strategies for coping with chronic illness.

While living with liver disease can be challenging, there are things you can do to keep your liver as healthy as possible. You and your healthcare providers can work as a team to keep your disease under control, manage your symptoms, and maximize your quality of life.

Liz Highleyman is a San Francisco-based freelance medical writer, writing for the Bulletin of Experimental Treatments for AIDS (BETA) and the Hepatitis C Support Project's HCV Advocate.

Healthy Liver Tips

  • Get regular health check-ups, including liver function tests.
  • Avoid or limit consumption of alcohol and recreational drugs.
  • Avoid toxic substances such as pesticides, solvents and paint thinners.
  • Eat a healthy, well-balanced diet.
  • Get regular, moderate exercise.
  • Drink plenty of water.
  • Take no more than the recommended doses of medications.
  • Be careful when using multiple drugs, herbs, or drugs and herbs together.
  • Inform healthcare providers about all drugs, herbs, supplements, and alternative therapies you are using.
  • Get vaccinated against hepatitis A and B.