Assessment of ALT Level of 223 in a Female
An ALT level of 223 in a female is considered a severe elevation, not a moderate elevation, as it exceeds 10 times the upper limit of normal for women. 1
Understanding ALT Reference Ranges and Classification
- Normal ALT levels for women are 19-25 IU/L, significantly lower than the traditional laboratory upper limits of normal 1, 2
- ALT elevations are classified as: 1
- Mild: <5 times the upper reference limit
- Moderate: 5-10 times the upper reference limit
- Severe: >10 times the upper reference limit
Calculation of Severity for This Case
- Using the upper reference limit of 25 IU/L for women 1, 2:
- 5× ULN = 125 IU/L
- 10× ULN = 250 IU/L
- An ALT of 223 IU/L is approximately 9 times the upper limit of normal, placing it at the high end of moderate elevation, approaching severe elevation 1
Clinical Significance of This Elevation
- ALT is highly specific for liver injury due to its low concentrations in skeletal muscle and kidney, making this elevation concerning for significant hepatocellular damage 1, 2
- ALT elevation of ≥5× ULN is rare in conditions like NAFLD/NASH and usually should not be attributed to these conditions alone 1
- This level of elevation warrants prompt evaluation for potential causes including: 1
- Viral hepatitis (acute or chronic)
- Drug-induced liver injury
- Autoimmune hepatitis
- Ischemic hepatitis
- Acute biliary obstruction
Recommended Approach for This Level of Elevation
- Immediate evaluation is warranted rather than monitoring, as this level suggests significant hepatocellular injury 1
- Complete liver function tests should be performed, including AST, alkaline phosphatase, bilirubin, albumin, and prothrombin time 2
- Testing for viral hepatitis (A-E), autoimmune markers, and review of all medications and supplements is essential 1, 2
- Imaging studies (starting with ultrasound) should be performed promptly to evaluate for structural causes 2
Important Considerations and Pitfalls
- Women have lower normal ALT ranges than men, making this elevation even more significant 1, 3
- Body mass index correlates with ALT levels, but an elevation of this magnitude is unlikely to be explained by BMI alone 4, 5
- Exercise and muscle injury can elevate AST more than ALT; if both are elevated, consider checking creatine kinase to rule out muscle origin 1
- Alcohol consumption should be assessed, as it can significantly impact liver enzyme levels 1
Conclusion
An ALT of 223 IU/L in a female represents a significant hepatocellular injury that falls at the high end of moderate elevation (approaching severe) and requires prompt and thorough evaluation to identify the underlying cause and prevent further liver damage 1, 2.