what causes your liver enzymes to be high
Mildly Elevated Liver Transaminase Levels: Causes and Evaluation
Am Fam Physician. 2017 December 1;96(11):709-715.
Patient information: Come across related handout on elevated liver enzymes, written by the authors of this article.
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Article Sections
- Abstract
- Causes of Elevated Liver Transaminase Levels
- Suggested Diagnostic Evaluation
- References
Mild, asymptomatic elevations (less than five times the upper limit of normal) of alanine transaminase and aspartate transaminase levels are common in primary care. It is estimated that approximately 10% of the U.South. population has elevated transaminase levels. An arroyo based on the prevalence of diseases that cause asymptomatic transaminase elevations can help clinicians efficiently identify common and serious liver disease. The most common causes of elevated transaminase levels are nonalcoholic fat liver disease and alcoholic liver illness. Uncommon causes include drug-induced liver injury, hepatitis B and C, and hereditary hemochromatosis. Rare causes include blastoffone-antitrypsin deficiency, autoimmune hepatitis, and Wilson disease. Extrahepatic sources, such as thyroid disorders, celiac sprue, hemolysis, and muscle disorders, are also associated with mildly elevated transaminase levels. The initial evaluation should include an assessment for metabolic syndrome and insulin resistance (i.east., waist circumference, blood pressure, fasting lipid level, and fasting glucose or A1C level); a complete claret count with platelets; measurement of serum albumin, fe, total atomic number 26-binding capacity, and ferritin; and hepatitis C antibody and hepatitis B surface antigen testing. The nonalcoholic fat liver affliction fibrosis score and the alcoholic liver disease/nonalcoholic fat liver disease index can be helpful in the evaluation of mildly elevated transaminase levels. If testing for common causes is consistent with nonalcoholic fatty liver disease and is otherwise unremarkable, a trial of lifestyle modification is appropriate. If the elevation persists, hepatic ultrasonography and further testing for uncommon causes should be considered.
Balmy, asymptomatic elevations of alanine transaminase (ALT) and aspartate transaminase (AST) levels, divers as less than five times the upper limit of normal, are common in principal intendance. The prevalence of elevated transaminase levels is estimated to exist approximately 10%, although less than 5% of these patients have a serious liver affliction.1,ii Understanding the epidemiology of each condition that causes asymptomatic elevated transaminase levels can guide the evaluation.3–6 Elevations greater than v times the upper limit of normal should prompt immediate evaluation6 but are beyond the scope of this article.
WHAT IS NEW ON THIS TOPIC: MILDLY ELEVATED LIVER TRANSAMINASE LEVELS
The NAFLD fibrosis score is a calculator that uses clinical data to predict run a risk of liver-related complications and death from advanced illness. Clinicians should refer patients with a high NAFLD fibrosis score, increased chance of progression, or coexisting chronic liver disease to a gastroenterologist.
In a two-twelvemonth prospective study in the Great britain that included nearly i,300 chief intendance patients with abnormal transaminase levels, excluding fat liver illness (38% of patients), less than 5% of diagnostic workups revealed significant liver disease, and only 17 persons (ane.three%) had serious liver illness that required immediate handling.
NAFLD = nonalcoholic fatty liver disease.
SORT: KEY RECOMMENDATIONS FOR Practise
| Clinical recommendation | Evidence rating | References |
|---|---|---|
| Consider gastroenterology referral for patients with persistent elevations of transaminase levels and for those who are at risk of nonalcoholic fat liver disease progression. | C | ten |
| Repeat liver enzyme testing is not necessary in the initial workup for elevated transaminase levels. | B | 43 |
| Lifestyle modifications with follow-upwards are advisable if history, physical exam, and workup advise nonalcoholic fat liver disease. | B | 4–6, 10, eleven, 43 |
| If the history and concrete exam are unrevealing, clinicians should initiate a stepwise epidemiologic arroyo to diagnosing the cause of elevated transaminase levels. | C | iii–5 |
Causes of Elevated Liver Transaminase Levels
- Abstruse
- Causes of Elevated Liver Transaminase Levels
- Suggested Diagnostic Evaluation
- References
Hepatocellular damage releases ALT and AST. Elevations in ALT generally are more specific for liver injury, whereas elevations in AST can as well be acquired by extrahepatic disorders, such as thyroid disorders, celiac sprue, hemolysis, and muscle disorders.7 Normal ALT levels are defined every bit 29 to 33 IU per L (0.48 to 0.55 μkat per Fifty) for males and nineteen to 25 IU per L (0.32 to 0.42 μkat per L) for females.half dozen The AST:ALT ratio tin can suggest a specific disease or give insight into liver disease severity. In a study differentiating alcoholic liver illness from nonalcoholic liver disease, alcoholic liver disease was suggested with an AST:ALT ratio greater than 2 (mean AST:ALT values were 152:70; positive likelihood ratio [LR+] = 17, negative likelihood ratio [LR–] = 0.49). On the other manus, nonalcoholic fat liver affliction (NAFLD) was associated with a ratio of less than ane (mean AST:ALT values were 66:91; LR+ = 80, LR– = 0.2).viii Still, causes of mild, asymptomatic elevation of transaminase levels can generally be categorized as common, uncommon, and rare (Tabular array 1).9
Table i.
Etiologies of Elevated Liver Transaminase Levels
| Etiologies | Clinical clues | Initial diagnostic testing |
|---|---|---|
| Mutual | ||
| NAFLD | Evidence of metabolic syndrome (increased waist circumference, elevated blood force per unit area, lipid pattern of loftier serum triglyceride levels and low serum loftier-density lipoprotein levels, elevated blood glucose levels or show of insulin resistance) | Fasting lipid levels, glucose (A1C) level; consider ultrasonography and NAFLD fibrosis score |
| Alcoholic liver disease | Excessive alcohol intake | Aspartate transaminase:alanine transaminase ratio (> two), mean corpuscular volume (increased), alcoholic liver disease/NAFLD index |
| Uncommon | ||
| Medications | Polypharmacy, certain herbal supplements | History |
| Hepatitis B | Immigrants from endemic countries, homo immunodeficiency virus infection, injection drug apply, men who have sex with men, household contacts or sex partners with the disease | Hepatitis B surface antigen testing |
| Hepatitis C | Born between 1945 and 1965, injection or intranasal drug use, blood transfusion before 1992, incarceration, hemodialysis, born to a mother with the disease, unregulated tattoo | Hepatitis C virus antibody testing |
| Hereditary hemochromatosis | Family history | Serum atomic number 26, full atomic number 26-binding capacity, ferritin measurements |
| Rare | ||
| Alpha1-antitrypsin deficiency | Early on-onset emphysema, family history | Serum alphai-antitrypsin measurement |
| Autoimmune hepatitis | Young women with autoimmune disorders | Serum protein electrophoresis, antinuclear antibody testing*; consider smooth muscle antibody and liver/kidney microsome type 1 antibiotic testing |
| Wilson disease | Eastern Europeans younger than 35 years, neuropsychiatric symptoms, Kayser-Fleischer rings | Serum ceruloplasmin measurement |
COMMON HEPATIC CAUSES
Nonalcoholic Fatty Liver Disease. A systematic review found that NAFLD is the nigh common cause of asymptomatic elevation of transaminase levels (25% to 51% of patients with elevated ALT or AST, depending on the written report population).1,ten NAFLD is divided into two subtypes. The first is nonalcoholic fat liver, defined as hepatic steatosis without inflammation. The second, more severe subtype is nonalcoholic steatohepatitis, which is characterized by hepatocyte injury with ballooning of cells, inflammation, and in severe cases, fibrosis.10 Nonalcoholic fatty liver is mostly benign and treated successfully with lifestyle modification (Table iixi–xiv), whereas patients with nonalcoholic steatohepatitis have pregnant run a risk of progression to cirrhosis and hepatocellular carcinoma. The prevalence of nonalcoholic steatohepatitis is estimated at 3% to v% of the adult population.x Thus, the clinical challenge is to decide which patients with NAFLD are at risk of progression.
Table 2.
Lifestyle Direction for Patients with NAFLD
| Intervention | Comments |
|---|---|
| Weight loss: aim to lose 7% to 10% body weight | For patients who are overweight or obese |
| General diet: low-fat to moderate-fat, low-carbohydrate, or Mediterranean nutrition | All accept been shown to exist effective in improving NAFLD, simply it is unclear which dietary component is superior |
| Fructose intake: avoid fructose-containing beverages and foods | High fructose intake is associated with NAFLD |
| Physical activity: 150 to 200 minutes per week of moderate to vigorous do* | Vigorous activity may amend nonalcoholic steatohepatitis and fibrosis over moderate activeness |
| Alcohol intake: daily intake less than 30 g for men and less than 20 g for women† | Limiting alcohol intake may lower the run a risk of NAFLD |
| Coffee drinking: no liver-related limitations | Coffee drinking may lower the hazard of NAFLD |
Considering metabolic syndrome is associated with NAFLD, it should exist the leading consideration in individuals with increased waist circumference, elevated blood pressure, high serum triglyceride levels, low serum high-density lipoprotein cholesterol levels, and/ or insulin resistance.eleven Type 2 diabetes mellitus is an contained gamble factor for NAFLD and increases the take a chance of nonalcoholic steatohepatitis.15 NAFLD is strongly suggested in a patient with hepatic steatosis on imaging, without significant booze history (daily intake less than 30 grand for men and less than 20 thou for women; fourteen g of alcohol is equivalent to one standard drinkable: 12 oz of beer [5% alcohol], v oz of wine [12% booze], or 1.five oz of 80-proof spirits [forty% alcohol])sixteen and no other compelling or coexisting liver affliction. Ultrasonography is the preferred first-line imaging modality for diagnosing hepatic steatosis,6,11,17 but it does not readily differentiate between nonalcoholic fat liver and nonalcoholic steatohepatitis.
Given the variable progression of NAFLD, it is important to identify those at hazard of advanced disease. The presence of liver fibrosis has been shown to be the all-time predictor of progression.xviii Fibrosis is more mutual in patients older than fifty years.15 A number of clinical tests accept been developed to help identify patients with fibrosis in lieu of a liver biopsy. The NAFLD fibrosis score (Table 3) uses clinical data to predict risk of liver-related complications and death from avant-garde disease.xix Patients with a high NAFLD fibrosis score, increased risk of progression, or coexisting chronic liver disease should exist referred to a gastroenterologist.10 Vibration-controlled transient elastography has emerged every bit a useful noninvasive modality to assess for hepatic fibrosis and may help decide which patients should undergo liver biopsy. However, its use may be limited by operator experience and in patients with elevated body mass index.twenty
Table 3.
Useful Clinical Scores for Assessing Patients with Elevated Liver Transaminase Levels
| Clinical score | Use | Clinical variables needed |
|---|---|---|
| Alcoholic liver disease/NAFLD index http://world wide web.mayoclinic.org/medical-professionals/model-terminate-phase-liver-disease/alcoholic-liver-affliction-nonalcoholic-fat-liver-disease-index | Distinguish alcoholic liver affliction from NAFLD | ALT level, AST level, height, mean corpuscular volume, sex activity, weight |
| NAFLD fibrosis score http://nafldscore.com | Assess risk of hepatic fibrosis | Age, ALT level, AST level, body mass alphabetize, diabetes mellitus or glucose intolerance, platelet count, serum albumin level |
Alcoholic Liver Disease. Excessive alcohol intake is the master cause of liver-related bloodshed in western countries.21 Alcoholic liver affliction and NAFLD have pregnant overlap in disease spectrum and histopathology.22 If history does not clearly distinguish the two conditions, the alcoholic liver affliction/NAFLD alphabetize (Table 3) can exist used. This index differentiates the atmospheric condition based on ALT level, AST level, superlative, mean corpuscular volume, sex, and weight. It has an LR+ of 12 and an LR– of 0.07, and has been prospectively validated in several varied populations.22–24
UNCOMMON HEPATIC CAUSES
Drug-Induced Liver Injury. The true incidence of drug-induced liver injury is unknown and likely underreported, although it has been estimated at 19.one cases per 100,000 persons annually.25 A history eliciting prescription and over-the-counter medication use, including supplements, is critical in identifying drug-induced liver injury. With increasing utilize, supplements now cause 9% of drug-induced liver injury cases.25 Acetaminophen, another common medication, can cause elevated transaminase levels in therapeutic doses.26,27 Medications commonly associated with drug-induced liver injury are listed in Table 4.25,28 The National Institute of Diabetes and Digestive and Kidney Diseases and the National Library of Medicine take collaborated to develop Liver-Tox (http://www.livertox.nih.gov), a resources for clinical information almost drug-induced liver injury.
Table four.
Selected Medications Commonly Associated with Elevated Liver Transaminase Levels
| Antihypertensive |
| Lisinopril |
| Losartan (Cozaar) |
| Antimicrobial |
| Ciprofloxacin |
| Isoniazid |
| Ketoconazole |
| Pyrazinamide |
| Rifampin |
| Tetracycline |
| Chemotherapeutics |
| Imatinib (Gleevec) |
| Methotrexate |
| Pain relievers/anti-inflammatory |
| Acetaminophen |
| Allopurinol |
| Aspirin |
| Nonsteroidal anti-inflammatory drugs |
| Psychiatric |
| Bupropion (Wellbutrin) |
| Risperidone (Risperdal) |
| Selective serotonin reuptake inhibitors |
| Trazodone |
| Valproic acid (Depakene) |
| Other |
| Acarbose (Precose) |
| Amiodarone |
| Baclofen |
| Herbal and dietary supplements |
| Highly active antiretroviral therapy |
| Omeprazole (Prilosec) |
Statin-induced liver injuries are rare.29 Given the lack of evidence linking statins to elevated transaminase levels, the U.S. Nutrient and Drug Administration now recommends but baseline measurement of ALT and AST before initiation of statins, and does not recommend routine liver monitoring for patients taking statins.29 However, clinicians should consider testing if in that location is suspicion for drug-induced liver injury or other liver disease. Statins have as well been shown to be safe in stable chronic liver affliction such as NAFLD and hepatitis C.25
Viral Hepatitis. Hepatitis B and C are common causes of elevated transaminase levels.i In the United States, approximately 3.5 million persons have chronic hepatitis C virus infection, and up to ii.2 one thousand thousand accept hepatitis B virus infection.xxx The U.S. Preventive Services Task Strength recommends screening loftier-risk patients with hepatitis B surface antigen and hepatitis C virus antibody testing.31,32
Hereditary Hemochromatosis. Hereditary hemochromatosis is an autosomal recessive disease causing increased iron absorption in the intestines and release by tissue macrophages. Although the classic gene mutation is common in Northern European Caucasians, at one per 150 to 250 persons, the severe iron overload of hereditary hemochromatosis is only phenotypically expressed in approximately 10% of patients with the genotype.33,34
Balmy, asymptomatic elevations in liver enzymes can occur because fe itself does not elicit a significant inflammatory response in the liver. Transferrin saturation and serum ferritin level should be measured to rule out hereditary hemochromatosis in patients with elevated transaminase levels. Transferrin saturation of 45% or more, and serum ferritin levels of more 250 to 300 ng per mL (562 to 674 pmol per Lng per mL) in men or more than 200 ng per mL (449 pmol per Lng per mL) in women should prompt testing for the presence of the HFE gene.33 Higher thresholds for transferrin saturation (more than threescore% in men and more than 50% in women) have been shown to predict the presence of hereditary hemochromatosis with 95% accuracy.35 The homozygous C282Y gene mutation is responsible for lxxx% to 85% of cases.33
RARE CAUSES
Alpha1-Antitrypsin Deficiency. Alphaane-antitrypsin deficiency is a genetic condition that primarily causes chronic lung and liver disease. The prevalence is approximately one in three,000 to 5,000 persons, just only 10% of those with the affliction are diagnosed.36 In the liver, an accumulation of an aberrant alphai-antitrypsin protein results in progressive damage. Although there are more than than 100 alpha1-antitrypsin gene variants, more than than 95% of clinical disease is in ZZ homozygotes, also known every bit the PiZZ genotype.37,38 Blastoff1-antitrypsin deficiency should exist suspected in patients with early-onset emphysema, and elevations in liver enzymes or clinical findings of advanced liver affliction without a known cause. Diagnosis begins with testing for serum alpha1-antitrypsin deficiency. If levels are very low, protein phenotyping or genotyping to look for the PiZZ variant should follow.36
Autoimmune Hepatitis. The prevalence of autoimmune hepatitis is 11 to 17 per 100,000 persons.39 It occurs more than often in immature women and is associated with other autoimmune disorders. Hypergammaglobulinemia is common in patients with autoimmune hepatitis, with total immunoglobulin Thousand levels generally 1.2 to 3 times normal.40 Therefore, serum protein electrophoresis testing has high sensitivity for autoimmune hepatitis, ruling out the condition if results are normal. Although antinuclear antibody testing is commonly ordered, it has lower sensitivity and specificity.41 Other laboratory tests may include smooth muscle antibiotic and liver/kidney microsome blazon 1 antibody measurements.39
Wilson Disease. Wilson disease is a rare autosomal recessive disorder, occurring in approximately one in thirty,000 persons, and is related to ineffective copper metabolism. It commonly occurs in Eastern Europeans younger than 35 years.42 Kayser-Fleischer rings (copper deposition around the cornea) or neuropsychiatric symptoms are primal clinical clues. A serum ceruloplasmin measurement is the initial test.42 If ceruloplasmin levels are low, further investigation with 24-hr urine copper levels, genetic testing, and liver biopsy can be considered.
Extrahepatic Causes. A number of extrahepatic sources of asymptomatic transaminase elevations may be considered based on the clinical picture.6 For instance, thyroid disorders and celiac sprue take been associated with elevated transaminase levels.four If the clinical motion picture is consistent, hemolysis and strenuous exercise should be considered.7 Rhabdomyolysis and polymyositis are unlikely etiologies, simply creatine kinase or aldolase measurements should be considered in patients with significant myalgias.
Suggested Diagnostic Evaluation
- Abstruse
- Causes of Elevated Liver Transaminase Levels
- Suggested Diagnostic Evaluation
- References
A big prospective study performed in the United Kingdom evaluated nearly ane,300 principal care patients with abnormal transaminase levels or liver part testing for ii years to determine the cause of the abnormalities.43 Each patient underwent laboratory testing and liver ultrasonography. Excluding fat liver disease (found in 38% of the cohort), less than 5% of diagnostic workups revealed significant liver disease. Only 17 (1.3%) of 1,300 patients had serious liver disease that required immediate treatment—13 cases of viral hepatitis (1%) and four cases of hereditary hemochromatosis (0.3%). Notably, repeating liver enzyme testing did non appear to be efficient because 84% of results remained abnormal after one calendar month and 75% subsequently two years. This study, along with guidelines, informs the evaluation of mildly elevated transaminase levels in primary intendance (Figure 1).three–6,43
Direction of Mildly Elevated Liver Transaminase Levels
Effigy 1.
Algorithm for the management of mildly elevated liver transaminase levels. (ALT = alanine transaminase; AST = aspartate transaminase; NAFLD = nonalcoholic fat liver disease.)
Data from references 3 through half dozen, and 43.
Data Sources: A PubMed search was completed using the cardinal terms elevated, liver role tests, transaminases, and aminotransferases. In addition, we used the key words nonalcoholic fatty liver disease, alcoholic liver illness, viral hepatitis, hemochromatosis, alpha1-antitrypsin deficiency, autoimmune hepatitis, and Wilson's disease solitary or in combination with aminotransferases. The search included the "diagnosis" clinical study category and related articles in PubMed. Also searched were Essential Evidence and the updated guidelines from the American Association for the Study of Liver Affliction. Search dates: May 1, 2016, to April 8, 2017.
The views expressed in this manuscript are those of the authors and do not reflect the official policy or position of the Department of the Army, the Department of Defense, or the U.S. government.
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