What does it mean for an adult to have ALT of 44 and AST of 20?

ALT 44 and AST 20: Clinical Interpretation

An ALT of 44 IU/L with AST of 20 IU/L represents a mild, isolated ALT elevation that is most commonly benign but warrants basic evaluation to exclude early liver disease, particularly nonalcoholic fatty liver disease (NAFLD) in patients with metabolic risk factors.

Understanding the Laboratory Values

Your ALT is mildly elevated while your AST remains normal, creating a specific pattern that provides diagnostic clues:

• ALT is the most liver-specific enzyme because it exists in low concentrations in skeletal muscle and kidney, whereas AST is present in cardiac muscle, skeletal muscle, kidneys, brain, and red blood cells 1, 2

• Normal ALT ranges are sex-specific and lower than most commercial laboratories report: 29-33 IU/L for males and 19-25 IU/L for females 1, 3

• Your ALT of 44 IU/L represents approximately 1.3-1.5× the upper limit of normal (mild elevation <5× ULN), which is classified as a mild hepatocellular pattern 1, 2

• **The AST/ALT ratio of 0.45 (<1) is characteristic of NAFLD, viral hepatitis, or medication-induced liver injury** rather than alcoholic liver disease, which typically shows AST/ALT >2 1, 2, 4

Most Likely Causes in Your Situation

The isolated mild ALT elevation with normal AST most commonly indicates:

• NAFLD is the most prevalent cause, affecting 20-30% of the general population and up to 70% in obese individuals, particularly if you have metabolic risk factors including obesity, diabetes, hypertension, or dyslipidemia 1, 2, 5

• Recent vigorous exercise or muscle injury can elevate ALT, though AST typically rises more prominently in these situations 1, 2

• Medication or supplement use, as drug-induced liver injury causes 8-11% of cases with mildly elevated liver enzymes 1

• Dietary changes or alcohol consumption, even at moderate levels, can cause transient elevations 1, 6

Recommended Initial Approach

Repeat the liver enzymes in 2-4 weeks to establish whether this is persistent or transient 1:

• If values normalize or decrease, continue monitoring only if symptoms develop 1
• If ALT remains elevated, proceed with systematic evaluation 1

Before repeat testing, consider these factors:

• Avoid intensive exercise for 48-72 hours before blood draw 2
• Review all prescription medications, over-the-counter drugs, and herbal supplements for hepatotoxic potential 1
• Assess alcohol consumption honestly (>14-21 drinks/week in men or >7-14 drinks/week in women suggests alcoholic contribution) 1

If ALT Remains Elevated on Repeat Testing

Order a complete liver panel including AST, ALT, alkaline phosphatase, GGT, total and direct bilirubin, albumin, and prothrombin time to assess for cholestatic patterns and synthetic function 1

Screen for common causes:

• Viral hepatitis serologies (HBsAg, anti-HBc IgM, anti-HCV) 1, 5
• Metabolic parameters: fasting glucose or HbA1c, fasting lipid panel 1
• Iron studies (ferritin, transferrin saturation) to screen for hemochromatosis 1
• Thyroid function tests, as thyroid disorders can cause transaminase elevations 1

Consider abdominal ultrasound as first-line imaging with 84.8% sensitivity and 93.6% specificity for detecting moderate to severe hepatic steatosis, which can identify fatty liver, biliary obstruction, and structural abnormalities 1, 2

When to Escalate Care

Hepatology referral is warranted if 1:

• ALT remains elevated for ≥6 months without identified cause
• ALT increases to >5× ULN (>145-165 IU/L for males, >95-125 IU/L for females)
• Evidence of synthetic dysfunction develops (low albumin, elevated INR)
• FIB-4 score >2.67 indicating high risk for advanced fibrosis

Important Caveats

• Mild asymptomatic ALT increases (1-3× ULN) are often not specific and may be related to NAFLD, dietary changes, or vigorous exercise 6, 5

• Normal ALT does not exclude significant liver disease, as up to 10% of patients with advanced fibrosis may have normal ALT using conventional thresholds 1

• The AST/ALT ratio can change with disease progression—if your ratio rises to >1 over time in the absence of alcohol use, this suggests possible development of cirrhosis and requires urgent evaluation 1, 4

• Do not assume this elevation is benign without proper evaluation, as ALT is highly specific for liver injury and persistent elevation warrants investigation even at mild levels 1, 7, 3