From the Guidelines
These liver enzyme values indicate moderate liver injury, with ALT (132 U/L) being significantly elevated and AST (62 U/L) mildly elevated, suggesting a hepatocellular injury pattern. The pattern of elevation (ALT>AST) is commonly seen in viral hepatitis, medication-induced liver injury, and non-alcoholic fatty liver disease, as noted in the study by 1. I recommend further evaluation to determine the underlying cause, starting with a complete medical history focusing on medication use, alcohol consumption, and risk factors for viral hepatitis.
Additional laboratory testing should include:
- A comprehensive metabolic panel
- Complete blood count
- Coagulation studies (PT/INR)
- Viral hepatitis serologies (hepatitis A, B, and C)
- Autoimmune markers (ANA, anti-smooth muscle antibody), as suggested by the study 1. Abstinence from alcohol is essential during this evaluation, given that alcohol-induced liver disease is a common cause of fatty liver disease, with an AST:ALT ratio generally >2, as noted in the study by 1.
If the patient is taking potentially hepatotoxic medications, these should be reviewed with their prescribing physician for possible discontinuation. Ultrasound of the liver should be performed to assess for structural abnormalities, fatty infiltration, or biliary obstruction. Follow-up testing in 2-4 weeks is recommended to monitor trends in these enzymes. If values continue to rise or symptoms develop (jaundice, abdominal pain, fatigue), more urgent evaluation by a gastroenterologist or hepatologist would be warranted, considering the potential for progressive liver disease, such as nonalcoholic steatohepatitis (NASH) and cirrhosis, as discussed in the study by 1.
From the Research
Elevated Liver Transaminase Levels
The provided liver transaminase levels are ALT 132 and AST 62. According to the studies, elevated transaminase levels may be associated with significant underlying liver disease and increased risk of liver-related and all-cause mortality 2, 3, 4.
Possible Causes
The most common causes of mildly elevated transaminase levels are:
- Metabolic dysfunction-associated steatotic liver disease (MASLD) and alcoholic liver disease 2, 5
- Nonalcoholic fatty liver disease (NAFLD) 5, 4
- Viral hepatitis (hepatitis B and C) 3, 5, 4
- Hemochromatosis 2, 5, 4
- Autoimmune hepatitis 2, 5, 6
- Alpha-1 antitrypsin deficiency 2, 5
- Wilson disease 2, 3, 5
- Extrahepatic conditions such as celiac disease, hyperthyroidism, rhabdomyolysis, and pregnancy-associated liver disease 2, 5
Evaluation and Testing
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
- Ferritin 2, 5, 4 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 2.
Further Investigation
Further testing may include:
- Ultrasonography
- Measurement of α(1)-antitrypsin and ceruloplasmin
- Serum protein electrophoresis
- Antinuclear antibody, smooth muscle antibody, and liver/kidney microsomal antibody type 1 testing 5, 4 Referral for further evaluation and possible liver biopsy is recommended if transaminase levels remain elevated for six months or more 5, 4.