Causes and Evaluation of Mildly Elevated Liver Transaminase Levels
ROBERT C. OH, LTC, MC, USA, and THOMAS R. HUSTEAD, LTC, MC, USA, Tripler Army Medical Center Family Medicine Residency Program, Honolulu, Hawaii
Am Fam Physician. 2011 Nov 1;84(9):1003-1008.
http://www.aafp.org/afp/2011/1101/p1003.pdf
LFTs are a commonly ordered lab in practice. Mildly elevated liver transaminase levels (less than 5x the upper limit of normal) require further workup. ALT is specific for the liver, whereas AST is seen in liver, muscle and red blood cells. Nonalcoholic fatty liver disease is the most common cause of mildly elevated LFTs. It can be broken down into two subtypes. Hepatic steatohepatitis is more benign and generally does not progress to severe disease. Nonalcoholic steatohepatitis has an increased risk of progression to severe disease. The ratio of AST/ALT will be less than 1. Nonalcoholic fatty liver disease is commonly associated with those patients who have diabetes, obesity, hypertriglyceridemia, and metabolic syndrome. Ultrasound and biopsy may be considered when diagnosing this disease. A biopsy will show inflammation and fibrosis. Alcoholic liver disease will have a AST/ALT ratio greater than 2, as well as an elevated y-glutamyl transpeptidase level.
There are many many medications that can cause a mild elevation of liver transaminases, including acetaminophen and statins. levels will spontaneously resolve in most patients taking statins. It is safe in patients with chronic liver disease. Statins may even lower transaminases in patients with nonalcoholic fatty liver disease.
Hepatitis B and C are also diseases to consider. Hepatitis B surface antigen and hepatitis C virus antibody can help identify infected patients. Hepatitis C may cause fluctuating transaminase levels, especially ALT. Hemochromatosis will have asymptomatic LFT elevations as well as transferrin saturation and ferritin. Less common causes consist of alpha antitrypsin deficiency, autoimmune hepatitis, wilson's disease, hemolysis, strenuous exercise, and celiac disease.
In evaluating a patient with elevated transaminases, a proper history and exam should be performed. The patient should be asked about alcohol usage, medications, supplements, vitamins, and herbs. Hepatotoxic chemicals should be halted and labs should be retested in 3-4 weeks. Patients should also be assessed for metabolic syndrome by checking BMI, waist circumference, fasting lipids, glucose levels, and possibly ultrasound. If the LFTs remain elevated, then common causes should be ruled out. Testing for hepatitis B, hepatitis C, iron, ferritin, and TIBC should be done. Prothrombin time, albumin, platelet count, and CBC may be help tests to order. If the cause is still not found, the patient should be observed with instructions for lifestyle modifications and reassessed in 6 months. A liver biopsy or referral to a specialist may be needed.
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