From the Guidelines
Hepatic inflammation typically presents with a pattern of elevated liver function tests (LFTs) characterized by predominant increases in aminotransferases (ALT and AST), as seen in hepatocellular injury, which is the most common cause of abnormal LFTs 1. The pattern of LFT derangement is crucial in distinguishing hepatocellular injury from cholestatic or mixed patterns, guiding diagnostic workup and treatment approaches.
- In acute inflammation, ALT is often higher than AST, while chronic inflammation may show an AST:ALT ratio greater than 1.
- Alkaline phosphatase and gamma-glutamyl transferase may be mildly elevated, but less prominently than aminotransferases. Initial management includes identifying and removing the underlying cause, whether it's viral hepatitis, alcohol, medications, or autoimmune conditions.
- For medication-induced inflammation, discontinue the offending drug, as recommended in the evaluation of patients with treatment-emergent ALT elevation during clinical trials with anti-cancer drugs 1.
- For alcoholic hepatitis, complete alcohol cessation is essential.
- For viral hepatitis, specific antivirals may be indicated depending on the virus type.
- For autoimmune hepatitis, prednisone starting at 40-60mg daily with gradual taper and addition of azathioprine 50-150mg daily as a steroid-sparing agent is typically recommended. Supportive care includes adequate hydration, nutritional support, and monitoring for complications like coagulopathy or encephalopathy.
- Serial LFT monitoring every 1-2 weeks initially is important to assess response to treatment, and to evaluate for treatment-related GI and hepatic adverse effects in patients undergoing drug treatment for COVID-19 1. The R value, calculated as (ALT/ALT ULN)/(ALP/ALP ULN), can help characterize the phenotype of injury observed with a particular drug, with an R value ≥5 defining hepatocellular injury, whereas R ≤ 2 indicates cholestatic injury, and R > 2 < 5 is consistent with a mixed injury pattern 1.
From the Research
Hepatic Inflammation and LFT Derangement Pattern
Hepatic inflammation is a complex process that involves the activation of various immune cells and the release of pro-inflammatory cytokines, which can lead to liver damage and derangement of liver function tests (LFTs) 2, 3. The pattern of LFT derangement can vary depending on the underlying cause of hepatic inflammation.
Causes of Hepatic Inflammation
Some common causes of hepatic inflammation include:
- Viral hepatitis, such as hepatitis B and C 4
- Alcohol-induced liver disease 3
- Non-alcoholic steatohepatitis (NASH) 3
- Autoimmune hepatitis 3
LFT Derangement Pattern
The LFT derangement pattern in hepatic inflammation can include:
- Elevated liver enzymes, such as alanine transaminase (ALT) and aspartate transaminase (AST) 2
- Elevated bilirubin levels 3
- Decreased albumin levels 3
- Prolonged prothrombin time (PT) and international normalized ratio (INR) 5, 6
Treatment and Management
Treatment and management of hepatic inflammation depend on the underlying cause and can include: