From the Guidelines
More than 50% of patients with alcoholic cirrhosis can have normal liver enzyme levels, making liver enzymes an unreliable tool for screening. This is based on recent evidence from a 2022 study published in Liver International 1, which highlights the limitations of using liver enzymes, such as ALT, for detecting advanced fibrosis or cirrhosis in patients with alcohol-related liver disease. The study notes that numerous studies have found normal ALT levels in more than 50% of advanced fibrosis cases, rendering ALT levels obsolete for effective screening. Additionally, another study by Harris et al, as mentioned in the same publication, found that the percentage of patients with fibrosis and normal ALT levels ranged from 40% to 74% 1. Key points to consider in patients with alcoholic cirrhosis include:
- Normal liver enzyme levels do not rule out cirrhosis
- Imaging studies, such as ultrasound, CT, or MRI, and sometimes liver biopsy, are essential for accurate diagnosis
- Clinicians should consider other markers of liver dysfunction, such as decreased albumin, elevated bilirubin, prolonged prothrombin time, or thrombocytopenia, in patients with risk factors for cirrhosis but normal enzymes. Given the high percentage of patients with normal liver enzyme levels, it is crucial not to exclude alcoholic cirrhosis based solely on normal liver enzymes, especially in patients with a history of significant alcohol consumption.
From the Research
Liver Enzyme Levels in Alcoholic Cirrhosis
- The study 2 found that in a cohort of 78 patients with alcoholic cirrhosis, 70 had a normal ALT and 12 had a normal AST.
- The average AST for all patients was 59 ± 34 U/L (ULN = 35 U/L), and the average ALT was 27 ± 13 U/L (ULN = 45 U/L).
- This suggests that a significant percentage of patients with alcoholic cirrhosis can have normal or near-normal liver enzyme levels.
Percentage of Patients with Normal Liver Enzyme Levels
- The study 2 reported that approximately 90% of patients with alcoholic cirrhosis had a normal ALT level.
- However, it's essential to note that the study also found that there was no correlation between complications or death and aminotransferase levels.
- This implies that liver enzyme levels may not be a reliable indicator of the severity of alcoholic cirrhosis or the risk of complications.
Clinical Implications
- The study 2 highlights the importance of clinicians being cautious when interpreting aminotransferase levels in patients with alcoholic cirrhosis.
- The presence of normal or near-normal liver enzyme levels does not necessarily indicate a better prognosis or lower risk of complications.
- Other factors, such as the patient's overall health, presence of comorbidities, and adherence to treatment, should be taken into account when assessing the severity of alcoholic cirrhosis and the risk of complications.