What is causing the elevated liver enzymes and abnormal lipid profiles in this patient?

Evaluation of Elevated Liver Enzymes in an Elderly Patient

The most likely cause of this patient's mildly elevated transaminases (AST 61, ALT 82) is non-alcoholic fatty liver disease (NAFLD), given the clinical context and laboratory pattern, though a comprehensive etiologic workup is essential to exclude other treatable causes. 1, 2

Clinical Pattern Recognition

The laboratory pattern strongly suggests NAFLD:

• **AST:ALT ratio <1** (61:82 = 0.74), which is characteristic of NAFLD and distinguishes it from alcohol-induced liver disease where the ratio is typically >2 2
• Mild aminotransferase elevations (<5 times upper reference limit) are typical of NAFLD 2
• Borderline elevated calcium (10.4 mg/dL) and elevated albumin/creatinine ratio (38 mg/g) suggest possible metabolic syndrome components 1, 2
• Lipid profile shows borderline elevated triglycerides (136 mg/dL) and relatively preserved HDL (64 mg/dL), consistent with metabolic risk factors 2

Essential Diagnostic Workup

Do not simply repeat the same liver tests—investigate the etiology immediately, as 84% of abnormal liver tests remain abnormal at 1 month and 75% at 2 years. 1

Core Panel Required (First-Line Testing):

• Viral hepatitis screening: HBsAg, anti-HBc (IgG, IgM), anti-HCV with reflex HCV RNA 1
• Autoimmune markers: ANA, ASMA, quantitative immunoglobulins (IgG, IgM, IgA) 1
• Iron studies: Ferritin and transferrin saturation (>45% suggests hemochromatosis) 1
• Right upper quadrant ultrasound: To assess for steatosis, biliary obstruction, or hepatic metastases 1, 3
• Metabolic syndrome assessment: Fasting glucose, HbA1c, complete metabolic panel 2

Critical History Elements:

• Alcohol intake: Quantify in units per week using AUDIT-C screening 1
• Medication review: All prescribed, over-the-counter, herbal supplements, and dietary supplements 1, 3
• Metabolic risk factors: Obesity, diabetes, hypertension, insulin resistance 1, 2
• Muscle injury or excessive exercise: Can elevate transaminases; check CK if suspected 1

Lipid Profile Interpretation

The lipid values (LDL 93, HDL 64, TC 181, TG 136) are not significantly abnormal and do not require immediate intervention:

• LDL-C of 93 mg/dL is within acceptable range for primary prevention 4
• Triglycerides of 136 mg/dL are borderline elevated but commonly seen with NAFLD 2
• The lipid pattern does not explain the liver enzyme elevation but supports metabolic syndrome as an underlying risk factor 2

Critical Pitfalls to Avoid

The magnitude of liver enzyme elevation does not correlate with disease severity or prognosis. 1, 2 Patients with significant liver fibrosis may have normal or minimally elevated liver enzymes, making clinical assessment and risk stratification essential 1.

Do not assume this is a transient finding. Only repeat testing if there is high clinical suspicion of an acute, self-limited insult (e.g., recent viral illness, muscle injury) 1.

Isolated elevated ferritin is commonly seen in NAFLD and alcohol excess (dysmetabolic iron overload syndrome) and does not necessarily indicate hemochromatosis unless transferrin saturation is also >45% 1.

Risk Stratification for NAFLD

If NAFLD is confirmed after excluding other etiologies:

• Calculate FIB-4 score or NAFLD Fibrosis Score to assess risk of advanced fibrosis 1, 2
• FIB-4 <1.3 (or <2.0 if age >65) indicates low risk of advanced fibrosis 1
• Consider second-line testing (Enhanced Liver Fibrosis [ELF] score, transient elastography/FibroScan) if intermediate or high risk 1

Statin Considerations

If the patient is on or being considered for statin therapy (given lipid profile):

• Mild transaminase elevations are not a contraindication to statin therapy 4
• Persistent elevations >3× ULN on two occasions occurred in only 0.7% of atorvastatin-treated patients in clinical trials 4
• Monitor liver enzymes but do not routinely discontinue statins for mild elevations, as statins may actually improve NAFLD-related liver injury 4, 5

Immediate Actions

1. Order core liver etiology panel (viral hepatitis, autoimmune markers, iron studies) 1, 3
2. Obtain right upper quadrant ultrasound 1, 3
3. Assess for metabolic syndrome components (fasting glucose, HbA1c, blood pressure, waist circumference) 2
4. Review all medications and supplements for potential hepatotoxicity 1, 3
5. Quantify alcohol intake using validated screening tools 1

Referral Indications

Immediate referral is warranted if: unexplained jaundice, suspicion of hepatobiliary malignancy, or dilated bile ducts on imaging 1.

Specialist referral is indicated for: positive hepatitis B or C serology, autoimmune hepatitis (elevated IgG with positive autoantibodies), primary biliary cholangitis (positive anti-mitochondrial antibody), or hemochromatosis (transferrin saturation >45% with elevated ferritin) 1.