Can Sarcoidosis Cause Elevated LFTs?
Yes, sarcoidosis commonly causes elevated liver function tests, occurring in approximately 12% of patients who undergo routine screening, with hepatic granulomas found in 96% of those with abnormal LFTs who undergo biopsy. 1
Prevalence and Pattern of Liver Involvement
- Liver involvement occurs in up to 70% of sarcoidosis patients histologically, though most remain asymptomatic. 2
- Approximately 12% (95% CI, 6-19%) of sarcoidosis patients will have abnormal liver function tests when screened. 1
- Alkaline phosphatase elevation is more characteristic of hepatic sarcoidosis than transaminase elevation. 1
- Hepatic involvement is more common in African Americans than white individuals. 1
Clinical Presentation
- Most patients with hepatic sarcoidosis are asymptomatic, with only laboratory abnormalities detected on screening. 3, 2
- When symptomatic, patients may present with right upper quadrant pain, pruritus, fatigue, or jaundice. 2, 4
- Hepatomegaly is commonly observed on physical examination. 5
- Anicteric cholestasis is the typical biochemical pattern. 5
Screening Recommendations from American Thoracic Society Guidelines
The American Thoracic Society (2020) recommends baseline serum alkaline phosphatase testing for all patients with sarcoidosis who have no hepatic symptoms (conditional recommendation, very low-quality evidence). 1
- The ATS makes no recommendation for or against baseline serum transaminase testing. 1
- Annual screening for liver involvement is recommended even if initial screening is negative, primarily to avoid hepatotoxic treatments and identify patients requiring closer monitoring. 1
Diagnostic Confirmation
- Liver biopsy reveals non-caseating granulomas in 96% (95% CI, 88-99%) of patients with abnormal LFTs. 1
- Asteroid bodies may be present within granulomas. 3
- Biopsy is essential to differentiate hepatic sarcoidosis from other granulomatous liver diseases and primary biliary cholangitis. 2, 6
Long-Term Complications and Prognosis
- Death from cirrhosis or liver failure is uncommon in hepatic sarcoidosis. 1
- Portal hypertension and cirrhosis can develop in long-standing cases but are rare complications. 2, 4
- The natural history ranges from spontaneous resolution to rapid progression to cirrhosis. 1
- Severe cases may rarely require liver transplantation. 2, 4
Critical Clinical Pitfall
Do not confuse prednisone-induced transaminitis with worsening hepatic sarcoidosis, as corticosteroid treatment itself can cause elevated transaminases and confound assessment. 1