Evaluation of ALT 223 and AST 118 as Moderate Hepatocellular Liver Injury
An ALT of 223 and AST of 118 is consistent with moderate hepatocellular liver injury based on current clinical guidelines. 1
Classification of Liver Injury
- Hepatocellular liver injury is characterized by predominant elevation of aminotransferases (ALT and AST) 2
- The R value (ratio of ALT/ULN to ALP/ULN) helps classify liver injury patterns, with R ≥5 defining hepatocellular injury 2
- ALT is more liver-specific than AST, making it the preferred marker for determining severity of hepatocellular injury 1, 3
- The American Association for the Study of Liver Diseases recommends classifying ALT/AST elevation as:
- Mild: <5× upper limit of normal (ULN)
- Moderate: 5-10× ULN
- Severe: >10× ULN 4
Analysis of the Presented Values
- With normal ALT ranges of 29-33 IU/L for males and 19-25 IU/L for females, an ALT of 223 represents approximately 7-11× ULN 1
- This places the ALT elevation in the moderate range (5-10× ULN) according to standard classification 4
- The AST:ALT ratio <1 (118:223 or approximately 0.53) is typical of non-alcoholic fatty liver disease, viral hepatitis, or medication-induced liver injury 1, 4
- This pattern differs from alcoholic liver disease, which typically presents with an AST:ALT ratio >2:1 4
Clinical Significance
- Moderate hepatocellular injury warrants further evaluation to determine the underlying cause 1
- Common causes of this pattern include:
- Non-alcoholic fatty liver disease (NAFLD)
- Viral hepatitis
- Medication-induced liver injury
- Less commonly: autoimmune hepatitis, Wilson's disease, hemochromatosis 4
- The absence of elevated bilirubin or alkaline phosphatase would suggest pure hepatocellular injury rather than mixed or cholestatic patterns 2
Recommended Evaluation
- Complete liver panel including alkaline phosphatase, total and direct bilirubin, albumin, and prothrombin time 1
- Viral hepatitis serologies (HBsAg, HBcIgM, HCV antibody) 1
- Review of medications, supplements, and alcohol consumption 1
- Abdominal ultrasound as first-line imaging 1
- Consider autoimmune markers (ANA, ASMA) if other causes are ruled out 2
Management Considerations
- For medication-induced liver injury, consider discontinuing suspected hepatotoxic medications 1
- For NAFLD, implement lifestyle modifications (weight loss, exercise, dietary changes) 1
- Monitor liver enzymes every 2-4 weeks initially to establish trends 1
- Consider hepatology referral if enzymes remain elevated for ≥6 months or if there is evidence of synthetic dysfunction 1
Important Caveats
- The interpretation of liver enzyme elevations should always consider the clinical context 1
- Muscle injury can also cause AST elevation, so creatine kinase should be measured if myopathy is suspected 1, 3
- Severe elevations (ALT >10× ULN) require more urgent evaluation and may indicate more severe liver damage 4
- Isolated biliary disease can occasionally present with markedly elevated transaminases in the absence of primary hepatic disease 5