From the Guidelines
Critically high ALT levels require immediate medical attention, and according to the most recent study 1, you should seek emergency care right away if your ALT is several times above the normal range. While waiting for medical care, it is essential to stop all potentially hepatotoxic medications, including acetaminophen (Tylenol), alcohol, and supplements. Do not attempt to self-treat critically high ALT levels. At the hospital, treatment will depend on the underlying cause, which may include viral hepatitis, drug-induced liver injury, autoimmune hepatitis, or acute liver failure. Healthcare providers may administer N-acetylcysteine for acetaminophen toxicity, corticosteroids for autoimmune causes, or supportive care with IV fluids and monitoring. ALT is an enzyme primarily found in liver cells, and when these cells are damaged or die, ALT leaks into the bloodstream. The degree of elevation often correlates with the extent of liver damage. After emergency treatment, you'll need follow-up testing to monitor liver function and may require lifestyle modifications, medication adjustments, or specific treatments for the underlying condition causing liver damage.
Some key points to consider when evaluating critically high ALT levels include:
- The severity of abnormal aminotransferase can be classified as mild, moderate, or severe, with moderate and severe being discussed collectively due to significant clinical overlap 1.
- Normal ALT levels are 29 to 33 IU/L (0.48-0.55 mkat/L) in men and 19 to 25 IU/L (0.32-0.42 mkat/L) in women 1.
- The causes of rising ALT include acute or chronic viral hepatitis, acute Budd-Chiari syndrome, ischemic hepatitis, autoimmune, hemochromatosis, medications/toxins, autoimmune, alpha1-antitrypsin deficiency, and Wilson disease 1.
- Nonalcoholic fatty liver disease (NAFLD) and alcohol-induced liver disease are common causes of mild increases in aminotransferases, while uncommon causes include drug-induced liver injury, hepatitis B, hepatitis C, and hereditary hemochromatosis 1.
It is crucial to note that the relationship between ALT level and disease progression has been confirmed in a long-term follow-up analysis of 3233 CHB patients from Hong Kong 1, highlighting the importance of prompt medical attention for critically high ALT levels. In real-life clinical practice, it is essential to prioritize the patient's morbidity, mortality, and quality of life when managing critically high ALT levels, and the most recent study 1 provides valuable guidance on the appropriate course of action. By following the recommendations outlined in the most recent study 1, healthcare providers can ensure the best possible outcomes for patients with critically high ALT levels.
From the Research
Causes of Critically High ALT Levels
- The most common causes of notably high ALT levels include choledocholithiasis, ischaemic hepatitis, viral hepatitis, and drug-induced liver injury (DILI) 2
- Other causes of high ALT levels include hepatobiliary malignancy, surgery/interventions, and other aetiologies 2
- In some cases, no specific aetiology may be found, accounting for approximately 6% of cases 2
Clinical Significance of High ALT Levels
- High ALT levels can be a marker of severe liver disease with variable aetiologies and prognosis 2
- Elevated ALT levels do not necessarily predict worse effects to come or indicate liver function 3
- ALT is a useful biomarker for detecting liver injury, but its limitations should be understood and considered when interpreting results 3
Diagnostic Work-up and Management
- A thorough diagnostic work-up, including investigations for risk factors and suspected causes, is essential for patients with high ALT levels 4
- Patients with suspected chronic viral hepatitis and liver cirrhosis should be referred to a hepatologist for further management 4
- Treatment options, such as ledipasvir/sofosbuvir, are available for certain causes of high ALT levels, including chronic hepatitis C 5