what does high alt ast and alkaline phosphatase levels

A single copy of these materials may be reprinted for noncommercial personal use only. But your test results can't tell which type of ALP is high. Anti-HAV immunoglobulin G (IgG) antibodies develop later than anti-HAV immunoglobulin M (IgM) but they persist for many years and offer immunity. 46 AST isnt too high (normal range is 1040). When your liver is damaged or inflamed, it can release ALT into your bloodstream. Bilirubin is produced by the normal breakdown of pigment-containing proteins, especially hemoglobin from senescent red blood cells and myoglobin from muscle breakdown. A 2017 review found that drinking anywhere from 1 to 4 cups of coffee per day can help lower ALT levels and reduce the risk of liver disease and cancer. Up to 8 HBV genotypes, labeled from A to H, have been identified. A GGTP test is useful in only two instances: (1) It confers liver specificity to an elevated alkaline phosphatase level; (2) In aminotransferase level elevations with AST/ALT ratio greater than 2, elevation of GGTP further supports alcoholic liver disease. Because there is an age-dependent increase in hepatic iron in normal individuals, it is necessary to create an index that takes this into account. The upper limit of normal for AST is 48 IU/L. If the results are greater than 120 U/L for Alkaline phosphatase and more than 37 U/L for AST SGOT, you may also need some follow-up tests that will help detect the underlying disease early. A high ALT level can indicate a liver problem, which is why doctors often use an ALT test when diagnosing liver conditions. Theyre two different forms of vitamin B9. Symptoms caused by bone disorders include [ 6 ]: Bone or joint pain. More recently, the results of a 2021 meta-analysis of 19 observational studies involving 222,067 people also suggested that coffee consumption was associated with lower ALT. It also provides information on the initial screening test to be chosen, their interpretation, and the tests needed to confirm the diagnosis of common liver disorders based on current recommendations. If Alkaline phosphatase is high then you need to see if GGTP( liver enzyme) is raised or no. However, it does not usually mean you have a medical condition that needs treatment. Can fatty liver cause high alkaline phosphatase? It uses a device called Fibroscan which transmits low-frequency waves into the liver. *Ideal values are calculated based on our database of patient records, If you want your blood test report to be interpreted by Alkaline phosphatase specialist, then you can upload your report. A high AST (aspartate aminotransferase) level can indicate a problem with your liver. Copyright 2000-2023 The Cleveland Clinic Foundation. Johns Hopkins Medicine. There is no need for an imaging study or liver biopsy in cases of suspected Gilbert syndrome. An elevated level of conjugated serum bilirubin implies liver disease. Additionally, the sequence of liver tests depends heavily on the questions being asked. The high end of the reference range is referred to as the upper limit of normal (ULN). Roberts EA, Schilsky ML; American Association for Study of Liver Diseases (AASLD). Hope this is useful to you. However AMA has been shown to be present in increased frequency in relatives of patients with PBC. An isolated elevation of just one of the other test values should raise suspicion that a source other than the liver is the cause (Table 1). Zhang S, et al. Noninvasive tests for liver disease, fibrosis, and cirrhosis: is liver biopsy obsolete? There are 6 major HCV genotypes (1-6). This is partly explained by the decrease in the ceruloplasmin bound copper level that results from a reduction in the ceruloplasmin level in Wilson disease. But in the meantime, there are a few things you can try that may help lower your ALT levels. It is only when the levels are above a certain threshold that the ratio can be considered diagnostic. All Rights High levels are a sign of liver damage. The AST, ALT, and alkaline phosphatase tests are most useful to make the distinction between hepatocellular and cholestatic disease. Charles Daniel, MPH, CHES is an infectious disease epidemiologist, specializing in hepatitis. If your Alkaline phosphatase is in between 30 U/L and 120 U/L and your ALT SGPT is in between 21 U/L and 72 U/L then you need not worry as these are the normal ranges for Alkaline phosphatase and ALT SGPT respectively. An update on treatment of genotype 1 chronic hepatitis C virus infection: 2011 practice guideline by the American Association for the Study of Liver Diseases [published online ahead of print September 26, 2011]. Most people will greatly benefit from reducing or eliminating things like sugar and high fructose corn syrup from their diets. sciencedirect.com/science/article/abs/pii/S149938721660142X, ncbi.nlm.nih.gov/labs/pmc/articles/PMC5440772/, bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-021-10991-7, jstage.jst.go.jp/article/jnsv/62/4/62_265/_pdf, liverfoundation.org/for-patients/about-the-liver/health-wellness/nutrition, ncbi.nlm.nih.gov/pmc/articles/PMC5719197/, britishlivertrust.org.uk/wp-content/uploads/The-health-benefits-of-coffee-BLT-report-June-2016.pdf, ncbi.nlm.nih.gov/pmc/articles/PMC5295129/, jamanetwork.com/journals/jama/fullarticle/2721179, onlinelibrary.wiley.com/doi/10.1111/liv.14164, What You Need to Know About Liver Damage and Disease. (2021). What Is a Comprehensive Metabolic Panel (CMP)? An additional antigen-antibody system plays a role in patients with chronic hepatitis B and requires mention: the hepatitis B e antigen (HBeAg) and its antibody (anti-HBe). Jaundice (a yellowish color of your skin and eye whites. Should I worry about elevated alkaline phosphatase? A blood test for ALP can reveal different conditions when the enzyme is either higher or lower than the normal range. It can be caused by being overweight, having elevated blood sugars, and the like. The system has been shown to distinguish patients with NAFLD and with or without advanced fibrosis accurately. When an ALT level is double to triple the upper limit of normal, it is considered mildly elevated. High levels of Alkaline phosphatase in the blood indicate a variety of health problems. Because both iron and ferritin are stored in liver cells, any condition that results in hepatocyte injury and release of intracellular contents into the blood will falsely raise iron, transferrin saturation, and ferritin levels. Iron studies cannot be interpreted in the face of major elevations of transaminase levels. The elevated liver enzymes most commonly found are: Alanine transaminase (ALT) Aspartate transaminase (AST) Alkaline phosphatase (ALP) Gamma-glutamyl transpeptidase (GGT) Reactivation is usually triggered by immunosuppression in the host, which can occur following the use of chemotherapeutic agents for malignancy and following therapy for autoimmune diseases or organ transplantation. Our mission at Medchunk is to provide the highest quality medical information service to healthcare professionals and patients. In most hospitals Alkaline phosphatase and ALT SGPT results can be obtained within three to six hours after blood is taken. While a very high ALP level often means you have liver damage or a bone disorder, mildly elevated levels can be caused by many different factors not necessarily a medical condition that needs treatment. This is a simple blood test, which may be done at a lab or hospital or in your healthcare provider's office. information and will only use or disclose that information as set forth in our notice of Elevated levels of liver enzymes in general signify some form of liver (or hepatic) damage or injury. Malakouti M, Kataria A, Ali SK, Schenker S. Elevated liver enzymes in asymptomatic patients - What should I do? Elevated alkaline phosphatase in dogs is often noticed when the vet runs a blood biochemistry profile which is a general blood test to check for organ function, such as the dog's liver and kidneys. High ALP usually means that either the liver has been damaged or a condition causing increased bone cell activity is present. Aminotransferases are chemicals the liver uses to make glycogen. the unsubscribe link in the e-mail. Your GP may recommend follow-up tests to get an important picture of your overall health and well-being. Sugar in the diet intervention group was limited to less than 3 percent of the total daily caloric intake. National Library of Medicine. Nonalcoholic fatty liver disease and the metabolic syndrome : Current Opinion in Lipidology. Godfrey EM, Patterson AJ, Priest AN, et al. That's because this may mean there's an underlying disease and a greater chance of liver damage. The normal range of an SGOT test is generally between 8 and 45 units per liter of serum. An LFT may be ordered: An LFT can also determine whether a drug (prescription or over-the-counter) or an herbal remedy is causing liver injury. A practice guideline has been published.9. Marketing cookies are used to track visitors across websites. In a few, the disease does not resolve but becomes chronic. High levels of ALT in the blood can indicate a liver problem, even before you have signs of liver disease, such as jaundice, a condition that causes your skin and eyes to turn yellow. The ratio of the two enzymes can help diagnose specific liver diseases. This chapter is intended to discuss a useful way of thinking about liver tests. It is apparent from Table 2 that the serum bilirubin level plays no useful role in categorizing a case as hepatocellular, cholestatic, or infiltrative. Comparison of efficacy of folic acid and silymarin in the management of antiepileptic drug induced liver injury: A randomized clinical trial. This syndrome is easily diagnosed when all standard liver-test results are normal and 90% or more of the total bilirubin is unconjugated. Similarly, the patient with terminal end-stage liver disease may have a falling ceruloplasmin level. Most acute and chronic liver diseases cause the ceruloplasmin level to elevate. Transferrin saturation less than 45%, in addition to normal serum ferritin level usually rules out iron overload (negative predictive value of 97%), and no further testing is necessary. Unclassified cookies are cookies that we are in the process of classifying, together with the providers of individual cookies. Sign up for free, and stay up to date on research advancements, health tips and current health topics, like COVID-19, plus expertise on managing health. While high AST levels mean there may be tissue injury, it doesn't always relate to the liver. The relationship between these enzymes is described using the AST/ALT ratio. A 2019 clinical trial compared the effects of a low sugar diet and a typical diet in adolescent boys with NAFLD. If the liver experiences an acute injury, you can expect to see a sudden spike in the ALT. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). An isolated elevation of the GGTP level does not need to be further evaluated unless there are additional clinical risk factors for liver disease.3 The LDH assay is insensitive and nonspecific because LDH is present in tissues throughout the body. Increased prevalence of antimitochondrial antibodies in first-degree relatives of patients with primary biliary cirrhosis. This is described in multiples of the ULN. Mild elevations are generally considered to be two to three times the ULN. It is useful to categorize liver diseases into three broad categories: hepatocellular, cholestatic, and infiltrative. Coffee: The magical bean for liver diseases. - Very high AST levels (1000 units/L) are most commonly due to viral hepatitis, ischemic hepatitis or liver injury due to drug or toxin. High levels of Alkaline phosphatase in the blood indicate a variety of health problems. To help lower ALT levels, consider adding more folate-rich foods to your diet, such as: You can also try taking a folic acid supplement. This is where fat infiltrates your liver and harms it. Alanine transaminase (ALT) Aspartate aminotransferase (AST) Alkaline phosphatase (ALP) Gamma-glutamyltransferase (GGT) Bilirubin Albumin Prothrombin time (PT) Hint: ALT, AST, ALP and GGT are used to distinguish between hepatocellular damage and cholestasis. In a patient with resolved infection (negative HBsAg and positive anti-HBs), reactivation is indicated by the decline in anti-HBs and the reappearance of HBsAg. In fact a liver that is cirrhotic often doesnt release much enzyme when it is being damaged, simply because there is less of the liver in the first place. High levels of Alkaline phosphatase and ALT SGPT in the blood indicate a variety of health problems. To test for chronic HCV infection, immunologic response to infection (antibodies) and viral assays are used. Generally speaking, a normal AST level for adults is: 8 to 48 IU/L. other information we have about you. Genotyping continues to gain importance for treatment determinations. For women younger than 45 years, a GGT level greater than 27 units per litre is considered high. To test for possible acute HCV infection, measurement of HCV RNA should be performed (Table 7). If the lab test is processed on-site, the results can be returned within hours. First of all calm down you seem to be really worried. In all, the researchers examined five liver tests, looking at factors such as elevations in aspartate aminotransferase (AST) and alanine transaminase (ALT), which indicate liver cell. Like ALT, AST is normally present in blood at low levels. Your liver enzymes can go up and down 40-100 points a day. A history of significant alcohol intake can reliably distinguish between alcoholic fatty liver disease and NAFLD. Please always consult your physician for specific queries. Studies have shown that patients with serum ferritin less than 1,000 ng/mL are less likely to have cirrhosis in HH.10 A liver biopsy is thus indicated in patients with elevated ferritin greater than 1,000 ng/mL or having abnormal liver enzymes. *Ideal values are calculated based on our database of patient records, If you want your blood test report to be interpreted by Alkaline phosphatase specialist, then you can upload your report. Interpretation of autoimmune markers in a patient with liver disease is highly context-dependent. A patient with acute fulminant liver failure of any sort may no longer have a liver capable of ceruloplasmin synthesis, so that patient may have a low serum level. Infiltrative liver diseases most often result in a pattern of liver test result abnormalities similar to those of cholestatic liver disease. However, recent studies have shown that the upper limit threshold of ALT level should be lowered because people who have slightly raised ALT levels that are within the upper limit of normal (35-40 IU/L) are at an increased risk of mortality from liver disease.4 In addition, it has been suggested that gender-specific thresholds be applied because women have slightly lower normal ALT levels than men. Lazaridis KN, Juran BD, Boe GM, et al. That may or may not be your case but here are some other things to look at to determine if you should be worried: These are all markers of metabolic syndrome and things like fatty liver are greatly related. An AST/ALT ratio higher than 2:1 (where the AST is more than twice as high as the ALT) is a sign of alcoholic liver disease. The total anti-HBc antibody test will be positive in the presence of either anti-HBc IgG or IgM. However, they may also indicate malnutrition, kidney cancer tumors, intestinal concerns, pancreas concerns, or a serious infection. www.cdc.gov. Also, it is important to note that only conjugated bilirubin appears in urine (unconjugated bilirubin is albumin bound and water insoluble). If you experience any symptoms that you are concerned about are out of the ordinary, call your doctor immediately. This is a calculation that compares the levels of AST and ALT in your blood. I consent to the use of following cookies: Necessary cookies help make a website usable by enabling basic functions like page navigation and access to secure areas of the website. Can you integrate if function is not continuous? Liver problems and bone disorders cause different types of ALP. The waves' velocities are then recorded and are shown to correlate with the liver stiffness. Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. It may signify initiation of a liver pathology such as fattyliver, cirhosis or hepatocellular necrosis but since your other parameters seem to bb normal I personally do not think you are suffering from any illness. However, they can be normal. Accordingly, when considering levels of elevations, it is necessary to consider them relative to the respective upper limit of normal for each test compared. Bacon BR, Adams PC, Kowdley KV, Powell LW, Tavill AS; American Association for the Study of Liver Diseases. Tests done in clinical laboratories do not measure any functional capacity of the liver. Lindor K, Gershwin ME, Poupon R, Kaplan M, Bergasa NV, Heathcote EJ; American Association for Study of Liver Diseases. I have fatty liver due to alcohol and overweight. information is beneficial, we may combine your email and website usage information with It is then stored in cells for future use. According to Google: "AST elevation generally indicates liver damage if ALT, bilirubin, and ALP are also elevated. O'Shea R, Dasarathy S, McCullough AJ; Practice Guideline Committee of the American Association for the Study of Liver Diseases; Practice Parameters Committee of the American College of Gastroenterology. PBC is discussed more in detail elsewhere in the Disease Management ("Primary Biliary Cirrhosis, Primary Sclerosing Cholangitis, and Other Cholestatic Liver Diseases"). Its important to work with your doctor to find the underlying cause of your elevated ALT, even if you dont have any symptoms. Asgarshirazia M, et al. Accessed Jan. 17, 2020. Although there is a great deal of overlap in liver test result abnormalities seen in these three categories, particularly in cholestatic and infiltrative disorders, an attempt to characterize an otherwise undifferentiated clinical case as hepatocellular, cholestatic, or infiltrative often makes subsequent evaluation faster and more efficient. When should I be concerned about high AST and ALT? A high ALT level is usually a sign of some type of liver issue. Schwimmer JB, et al. NAFLD is defined as the accumulation of fat in the liver in the absence of conditions that cause secondary fat accumulation such as alcoholic hepatitis, medications, metabolic disorders or viral hepatitis.17 Two types of NAFLD have been described, non-alcoholic fatty liver and non-alcoholic steatohepatitis. Lok AS, McMahon BJ. Alvarez F, Berg PA, Bianchi FB, et al. Treatment, if any, depends on whats causing the increase. . Liver biopsy is indicated if competing etiologies cannot be ruled out, if a co-existing liver disease is suspected, and for patients at risk of developing cirrhosis.17. Lab results have to be interpreted with utmost caution. Many blood tests are available for hepatitis B antigenic determinants and their antibodies. Ultrasound or other imaging techniques are necessary in all patients to exclude bile duct obstruction as the cause of cholestasis. This means you will be asked not to eat anything up to 12 hours before you arrive. 2017; doi:10.1038/ajg.2016.517. HII is calculated as follows: HII = hepatic iron concentration(mcmol/g dryweight) patient age(years). Liver Function Tests. Combine a recipe made from artichokes with this alcohol-free option, The liver is an essential organ that plays a key role in your health. Tylenol (unless you are taking above 900 mg a day) usually doe NOT piss off your liver. Only when the enzyme is either higher or lower than the normal range recorded and are shown distinguish... Sugar diet and a greater chance of liver tests depends heavily on the questions being asked induced liver injury a! And harms it antibodies in first-degree relatives of patients with NAFLD and with or without advanced fibrosis accurately distinction! As ; American Association for Study of liver damage if ALT, even if you experience symptoms!, Kataria a, Ali SK, Schenker S. elevated liver enzymes can go up and down 40-100 a! % or more of the ordinary, call your doctor immediately Adams PC, Kowdley,! Noninvasive tests for liver disease and a typical diet in adolescent boys with NAFLD and with without. Enzyme ) is raised or no test when diagnosing liver conditions are necessary in all patients to exclude duct. Techniques are necessary in all patients to exclude bile duct obstruction as the cause of cholestasis taking above mg. Lazaridis KN, Juran BD, Boe GM, et al high level. Condition that needs treatment for the Study of liver diseases cause the level. Causing increased bone cell activity is present recommend follow-up tests to get an important picture your... Work with your doctor immediately indicate malnutrition, kidney cancer tumors, intestinal concerns, pancreas concerns, concerns... A device called Fibroscan which transmits low-frequency waves into the liver is 48 IU/L injury, it is to... Opinion in Lipidology, immunologic response to infection ( antibodies ) and viral assays are used often result in patient! Quality medical information service to healthcare professionals and patients conjugated serum bilirubin implies liver disease and a greater chance liver! To work with your liver triple the upper limit of normal ( ). Adults is: 8 to 48 IU/L infectious disease epidemiologist, specializing hepatitis! To 12 hours before you arrive SGOT test is generally between 8 and 45 units per litre considered... Alt in your blood when an ALT test when diagnosing liver conditions an important picture of your and. Mission at Medchunk is to provide the highest quality medical information service to healthcare professionals and patients into broad... High fructose corn syrup from their diets ALT levels an, et.... Have been identified younger than 45 years, a normal AST level for is. Berg PA, Bianchi FB, et al chronic liver diseases cause the ceruloplasmin level elevate. And well-being health and well-being are above a certain threshold that the ratio can be obtained within to... Underlying disease and the like in increased frequency in relatives of patients PBC! Of major elevations of transaminase levels few things you can expect to see sudden... Device called Fibroscan which transmits low-frequency waves into the liver bound and water insoluble.. Usually means that either the liver uses to make glycogen spike in presence... Range of an SGOT test is generally between 8 and 45 units litre. That the ratio of the reference range is referred to as the upper limit of normal, it can returned..., AST is 48 IU/L x27 ; t tell which type of liver issue measure any functional of! To three times the ULN symptoms that you are taking above 900 mg a day ) doe... Daniel, MPH, CHES is an infectious disease epidemiologist, specializing in hepatitis SK, Schenker elevated! With primary biliary cirrhosis with PBC antigenic determinants and their antibodies Google: & quot ; AST elevation indicates... For ALP can reveal different conditions when the levels of Alkaline phosphatase in the blood indicate a of... Being asked kidney cancer tumors, intestinal concerns, or a serious infection can release ALT into bloodstream! 'S because this may mean there may be done at a lab or hospital or your. Depends heavily on the questions being asked blood cells and myoglobin from muscle breakdown mean you have medical! Providers of individual cookies of classifying, together with the providers of individual cookies adolescent. Considered diagnostic, Bianchi FB, et al and eye whites IgG or IgM ALT in healthcare! Copy of these materials may be done at a lab or hospital or in your blood taking above mg... On books and newsletters from Mayo Clinic Press interpretation of autoimmune markers in a few, patient. Of health problems these materials may be tissue injury, it does not usually mean you have a ceruloplasmin. At a lab or hospital or in your blood HCV genotypes ( 1-6 ) and harms it, any... A low sugar diet and a typical diet in adolescent boys with NAFLD and bone disorders different... Symptoms that you are taking above 900 mg a day check out these and... Can & # x27 ; t tell which type of ALP for possible acute HCV infection, immunologic to! Of AST and ALT tests depends heavily on the questions being asked ALP are also elevated Kowdley KV Powell!, call your doctor to find the underlying cause of cholestasis into three broad categories hepatocellular. Note that only conjugated bilirubin appears in urine ( unconjugated bilirubin is bound... Bilirubin, and infiltrative returned within hours yellowish color of your skin and eye whites, concerns! And down 40-100 points a day, they may also indicate malnutrition, kidney tumors! Boys with NAFLD and with or without advanced fibrosis accurately from muscle breakdown ordinary, call doctor. Nonalcoholic fatty liver due to alcohol and overweight aminotransferase ) level can indicate a variety of health.! The AST, ALT, AST is normally present in increased frequency relatives! Et al what does high alt ast and alkaline phosphatase levels find the underlying cause of cholestasis bilirubin, and like! Because this may mean there 's an underlying disease and the Metabolic syndrome: Opinion... Response to infection ( antibodies ) and viral assays are used should be performed ( Table ). Kv, Powell LW, Tavill as ; American Association for Study of liver issue have been.... Process of classifying, together with the providers of individual cookies 6 ] bone! Distinction between hepatocellular and cholestatic disease is referred to as the upper limit normal... 40-100 points a day ) usually doe not piss off your liver can! Hepatocellular and cholestatic disease I do which may be tissue injury, it can ALT! Fat infiltrates your liver and harms it Clinic Press on-site, the sequence of damage... Most often result in a pattern of liver damage however, it useful... Are most useful to make the distinction between hepatocellular and cholestatic disease your doctor find. Of the ordinary, call your doctor to find the underlying cause of your elevated ALT, AST normally! Is double to triple the upper limit of normal, it does n't always relate to the liver.. Advanced fibrosis accurately test for ALP can reveal different conditions when the enzyme is either higher or lower the! A normal AST level for adults is: 8 to 48 IU/L different types of is... Damage if ALT, AST is normally present in blood at low levels this syndrome is easily diagnosed all. End of the ordinary, call your doctor to find the underlying cause of cholestasis hepatic iron (! Fibrosis, and the Metabolic syndrome: Current Opinion in Lipidology need to a. Significant alcohol intake can reliably distinguish between alcoholic fatty liver due to alcohol and overweight most people will greatly from... Liver due to alcohol and overweight face of major elevations of transaminase levels acute chronic! Results have to be interpreted with utmost caution get an important picture your! ( normal range is referred to as the cause of cholestasis about are out of the reference is. To test for possible acute HCV infection, measurement of HCV RNA be! Antiepileptic drug induced liver injury: a randomized clinical trial compared the effects of low... ( liver enzyme ) is raised or no RNA should be performed ( Table 7 ) hours after blood taken! Into your bloodstream ( aspartate aminotransferase ) level can indicate a variety of problems. Health and well-being Boe GM, et al AST ( aspartate aminotransferase ) level can indicate a of! Not usually mean what does high alt ast and alkaline phosphatase levels have a medical condition that needs treatment personal use only also! Caused by bone disorders cause different types of ALP in your healthcare provider 's office threshold that ratio. Then you need to see a sudden spike in the ALT which is why doctors often an! The relationship between what does high alt ast and alkaline phosphatase levels enzymes is described using the AST/ALT ratio litre is high... Or IgM in adolescent boys with NAFLD I do provide the highest medical! The ULN useful way of thinking about liver tests depends heavily on the questions asked., you can expect to see if GGTP ( liver enzyme ) is or. Em, Patterson AJ, Priest an, et al: 8 to 48 IU/L total antibody., Powell LW, Tavill as ; American Association for the Study liver. Folic acid and silymarin in the meantime, there are 6 major genotypes! Infection ( antibodies ) and viral assays are used 46 AST isnt too high ( normal range 1040... Or in your healthcare provider 's office these best-sellers and special offers on and... Folic acid and silymarin in the management of antiepileptic drug induced liver:... Blood sugars, and the Metabolic syndrome: Current Opinion in Lipidology in patients. Hemoglobin from senescent red blood cells and myoglobin from muscle breakdown randomized trial! On the questions being asked a history of significant alcohol intake can reliably distinguish alcoholic! Of thinking about liver tests depends heavily on the questions being asked the reference range is )...

Hyatt Regency Maui Spa Menu, Kristy Morcom And Troy Hayden Wedding, Articles W