From the Guidelines
Transaminitis in hospitalized patients is most commonly caused by nonalcoholic fatty liver disease (NAFLD) and alcohol-induced liver disease, with other causes including viral hepatitis, medications, and ischemic hepatitis. The most recent and highest quality study, 1, highlights that NAFLD is the most common liver disease in first world countries, with a prevalence of 20% to 30% in the general population, and is a spectrum of fat deposition and hepatic inflammation followed by fibrosis due to metabolic insults.
Common Causes of Transaminitis
- Nonalcoholic fatty liver disease (NAFLD)
- Alcohol-induced liver disease
- Viral hepatitis (acute or chronic)
- Medications/toxins
- Ischemic hepatitis
- Autoimmune hepatitis
- Hemochromatosis
- Alpha1-antitrypsin deficiency
- Wilson disease
Evaluation and Management
When evaluating transaminitis, clinicians should first review the medication list and discontinue potential offending agents, assess for viral hepatitis through serologies, evaluate alcohol use history, and consider imaging to assess for biliary obstruction or hepatic congestion, as suggested by 1. It is also important to consider other causes of elevated liver enzymes, such as iron studies, thromboembolic event, or potential liver metastasis from primary malignancy.
Key Considerations
- The AST:ALT ratio is generally >2 in alcohol-induced fatty liver disease and <1 in metabolic disease-related fatty liver, as noted in 1.
- NAFLD is a spectrum of fat deposition and hepatic inflammation followed by fibrosis due to metabolic insults, and can coexist with nonalcoholic steatohepatitis (NASH), as described in 1.
- Transaminitis typically resolves with removal of the offending agent, though the timeline varies depending on the underlying cause and severity of liver injury.
From the Research
Common Causes of Transminitis
The most common causes of elevated transaminase levels, which are indicative of transminitis, are:
- Nonalcoholic fatty liver disease
- Alcoholic liver disease 2 Other uncommon causes include:
- Drug-induced liver injury
- Hepatitis B and C
- Hereditary hemochromatosis Rare causes of transminitis are:
- Alpha1-antitrypsin deficiency
- Autoimmune hepatitis
- Wilson disease Extrahepatic sources, such as thyroid disorders, celiac sprue, hemolysis, and muscle disorders, can also be associated with mildly elevated transaminase levels 2.
Evaluation of Transminitis
The initial evaluation of transminitis should include an assessment for metabolic syndrome and insulin resistance, as well as measurement of serum albumin, iron, total iron-binding capacity, and ferritin 2. The nonalcoholic fatty liver disease fibrosis score and the alcoholic liver disease/nonalcoholic fatty liver disease index can be helpful in the evaluation of mildly elevated transaminase levels 2.
Statin Use and Transminitis
Statin use has been associated with a transient asymptomatic elevation of serum aminotransferases in the first 12 weeks of therapy 3. However, clinical trials have demonstrated that statin therapy can improve and/or normalize aminotransferases and improve lipid levels without any reported adverse effects attributable to statin therapy in patients with nonalcoholic fatty liver disease, nonalcoholic steatohepatitis, and hepatitis C virus 3.