From the Guidelines
ALT elevation is a sensitive marker for liver injury and requires prompt evaluation to determine the underlying cause, with management depending on the cause, and may include lifestyle modifications, discontinuing hepatotoxic medications, or specific treatments for identified liver conditions. According to the most recent study 1, the evaluation of patients with treatment-emergent ALT elevation should include a thorough history, first-line testing such as serum creatine kinase, hepatitis A, B, C, and E testing, autoantibody and immunoglobulin testing, and hepatobiliary imaging. The severity of abnormal aminotransferase can be classified as mild, moderate, or severe, with moderate and severe elevations requiring prompt medical evaluation 1. Common causes of ALT elevation include non-alcoholic fatty liver disease, alcohol-induced liver disease, viral hepatitis, and certain medications 1. The R value, which is the ratio of the fold elevation of ALT to the fold elevation of ALP, can help characterize the phenotype of injury and determine the likelihood of hepatocellular or cholestatic injury 1.
Some key points to consider in the evaluation of ALT elevation include:
- The AST:ALT ratio can help differentiate between alcohol-induced and non-alcoholic fatty liver disease, with a ratio greater than 2 suggesting alcohol-induced liver disease 1
- The presence of autoantibodies and immunoglobulins can indicate autoimmune hepatitis 1
- Hepatobiliary imaging can help identify biliary obstruction, pancreatitis, and other causes of liver injury 1
- A liver biopsy may be necessary to confirm a diagnosis of autoimmune hepatitis or to determine the pattern and severity of drug-induced liver injury 1
Overall, the management of ALT elevation requires a thorough evaluation to determine the underlying cause and may involve lifestyle modifications, discontinuing hepatotoxic medications, or specific treatments for identified liver conditions. Prompt medical evaluation is necessary for significant elevations, and monitoring with repeat testing in 2-4 weeks may be appropriate for mild elevations in asymptomatic patients.
From the Research
Alt Elevation Causes
- Chronic alcohol consumption, drugs, non-alcoholic steatohepatitis (NASH) and chronic viral hepatitis are common causes associated with raised ALT and AST 2
- Non-hepatic causes of raised ALT and AST include polymyositis, acute muscles injury, acute myocardial infarction and hypothyroidism 2
Alt Elevation Treatment
- Tenofovir and entecavir are the most effective antiviral agents for chronic hepatitis B 3
- Ursodeoxycholic acid has a positive effect on the activity of serum transaminases and cholestasis indexes in acute viral hepatitis 4
- Entecavir, tenofovir disoproxil fumarate, and tenofovir alafenamide have similar efficacy in treatment-naive hepatitis B patients 5
- Tenofovir has superior short-term efficacy compared to entecavir for the treatment of acute-on-chronic liver failure due to reactivation of chronic hepatitis B 6