What is the significance of elevated Alanine Transaminase (ALT) of 85 and Aspartate Transaminase (AST) of 70 in a 36-year-old female in the emergency department?

From the Guidelines

For a 36-year-old female in the emergency department with ALT of 85 and AST of 70, I recommend a focused evaluation for acute liver injury, prioritizing a thorough history, physical examination, and additional laboratory testing to determine the underlying cause of the transaminase elevations, as suggested by the most recent guidelines 1. These values represent mild to moderate transaminase elevations, approximately 2-2.5 times the upper limit of normal. The mild elevation pattern with ALT slightly higher than AST suggests an acute hepatocellular process rather than alcoholic liver disease (where AST typically exceeds ALT) 1. Initial management should include:

• A thorough history focusing on medication use (including over-the-counter drugs, supplements, and acetaminophen), alcohol consumption, recent viral illnesses, and risk factors for viral hepatitis
• Physical examination to assess for jaundice, right upper quadrant tenderness, hepatomegaly, and signs of chronic liver disease
• Additional laboratory testing, including:
  • Bilirubin (total and direct)
  • Alkaline phosphatase
  • GGT
  • Albumin
  • PT/INR
  • Complete blood count
  • Basic metabolic panel
• Specific testing for viral hepatitis (Hepatitis A, B, and C), autoimmune markers (ANA, ASMA), and an ultrasound of the liver would be appropriate, as recommended by recent guidelines 1 While these elevations are concerning, they don't necessarily require hospitalization if the patient is stable, without significant symptoms, and has no evidence of hepatic synthetic dysfunction. Close follow-up within 1-2 weeks with repeat liver function tests is essential to monitor progression or resolution, as suggested by the American College of Radiology 1.

From the Research

Significance of Elevated ALT and AST

• Elevated Alanine Transaminase (ALT) of 85 and Aspartate Transaminase (AST) of 70 in a 36-year-old female may indicate a disturbance of hepatocellular integrity, which can be found in patients with viral hepatitis, genetic liver diseases, or drug-induced liver diseases 2.
• The most common causes of transaminase elevation are non-alcoholic fatty liver disease (NAFLD), alcohol intake, and hepatitis C virus infection 3.
• Mildly elevated transaminase levels (two to five times the upper limit of normal) are commonly associated with metabolic dysfunction-associated steatotic liver disease (MASLD) and alcoholic liver disease 4.
• Extrahepatic causes of elevated transaminases include celiac disease, hyperthyroidism, rhabdomyolysis, and pregnancy-associated liver disease 4, 5.

Evaluation and Management

• Initial laboratory testing should assess complete blood cell count with platelets, blood glucose, lipid profile, hepatitis B surface antigen, hepatitis C antibody, serum albumin, iron, total iron-binding capacity, and ferritin 4, 5.
• If MASLD is suspected, the FIB-4 Index Score or NAFLD Fibrosis Score can be used to predict which patients are at risk for fibrosis and may benefit from further testing or referral to a hepatologist 4.
• Patients with elevated transaminases should be counseled about moderation or cessation of alcohol use, weight loss, and avoidance of hepatotoxic drugs 4.
• An algorithmic approach can be taken to help narrow the spectrum of a differential diagnosis and ensure appropriate management and evaluation of the patient with elevated liver function tests 6.