Alanine aminotransferase and mortality in patients with type 2 diabetes (ZODIAC-38)

Elevated alanine transaminase is nonlinearly associated with in-hospital death in ICU-admitted diabetic ketoacidosis patients

AIMS

To investigate the association between alanine transaminase (ALT) and in-hospital death in patients admitted to the intensive care unit for diabetic ketoacidosis (DKA).

METHODS

A cohort of 2,684 patients was constructed from the eICU Collaborative Research Database. Baseline demographic and clinical characteristics were summarized. Cox regressions with restricted cubic spline functions were modelled to explore the association between alanine transaminase and in-hospital death. Subgroup analyses were conducted between sexes, age groups, and people with/without obesity.

RESULTS

After adjusting multiple confounders, a nonlinear, S-shaped association between ALT and in-hospital death was found. Compared to patients at median ALT, patients at the 90th percentile of ALT have a 1.88 (95 % confidence interval [CI]: 1.34-2.62) times higher hazard of in-hospital death in the unstratified cohort. Similar results were found in males (hazard ratio [HR] = 1.69, 95 % CI: 1.24-2.30); patients aged under 65 years (HR = 1.65, 95 % CI: 1.09-2.49); patients aged 65 years or above (HR = 3.45, 95 % CI: 1.67-7.14); non-obese patients (HR = 1.52, 95 % CI: 1.00-2.32); and obese patients (HR = 2.76, 95 % CI: 1.38-5.54).

CONCLUSIONS

Elevated ALT is robustly associated with in-hospital death in ICU-admitted DKA patients across several subgroups. Close monitoring of ALT in these patients is recommended.

High Aspartate Aminotransferase/Alanine Aminotransferase Ratio May Be Associated with All-Cause Mortality in the Elderly: A Retrospective Cohort Study Using Artificial Intelligence and Conventional Analysis

Low serum alanine aminotransferase (ALT) activity and high aspartate aminotransferase (AST)/ALT ratio may be associated with high mortality in the elderly. We aimed to confirm this in an 8-year retrospective cohort study. Clinical data for 5958 people living in a city aged 67−104 years were analyzed for their relationships with all-cause mortality using artificial intelligence (AI) and conventional statistical analysis. In total, 1413 (23.7%) participants died during the study. Auto-AI analysis with five rounds of cross-validation showed that AST/ALT ratio was the third-largest contributor to mortality, following age and sex. Serum albumin concentration and body mass index were the fourth- and fifth-largest contributors. However, when serum ALT and AST were individually considered in the same model, the individual serum ALT and AST activities were the seventh- and tenth-largest contributors. Conventional survival analysis showed that ALT, AST, and AST/ALT ratio as continuous variables were all associated with mortality (adjusted hazard ratios (95% confidence intervals): 0.98 (0.97−0.99), 1.02 (1.02−1.03), and 1.46 (1.32−1.62), respectively; all p < 0.0001). In conclusion, both AI and conventional analysis suggest that of the conventional biochemical markers, high AST/ALT ratio is most closely associated with all-cause mortality in the elderly.

Associations of liver volume and other markers of hepatic steatosis with all-cause mortality in the general population

AIMS

We examined the associations between liver volume and other quantitative and qualitative markers of hepatic steatosis with all-cause mortality in the general population.

METHODS

We included 2769 German middle-aged individuals with a median follow-up of 8.9 years (23,898 person-years). Quantitative markers used were serum liver enzymes and FIB-4 score, while qualitative markers of hepatic steatosis included magnetic resonance imaging (MRI) measurements of liver fat content and total liver volume. Cox proportional hazards models, adjusted for confounding factors, were undertaken to investigate the associations of liver volume and other markers of hepatic steatosis with all-cause mortality.

RESULTS

A larger MRI-assessed liver volume was associated with a nearly three-fold increased risk of all-cause mortality (Hazard Ratio = 3.16; 95% confidence interval 1.88; 5.30), independent of age, sex, body mass index, food frequency score, alcohol consumption and education level. This association was consistent in all subgroups considered (men vs. women; presence or absence of overweight/obesity, metabolic syndrome or diabetes). Higher serum liver enzyme levels and FIB-4 score were also significantly associated with higher all-cause mortality in the total population and in all subgroups. No independent associations were found between other quantitative and qualitative markers of hepatic steatosis and the risk of all-cause mortality.

CONCLUSIONS

We showed for the first time that larger liver volume was associated with a three-fold increase in long-term risk of all-cause mortality. This association remained significant after adjustment for age, sex, alcohol consumption, obesity and other coexisting metabolic disorders.

Serum alanine aminotransferase activity and risk factors for cardiovascular disease in a Caucasian population: the Tromsø study

Background

High and low levels of serum alanine aminotransferase (ALT) are both associated with cardiovascular diseases (CVD) risks especially in elderly, but the mechanisms are less known. This study investigated associations between ALT and CVD risk factors including effects of sex and age in a Caucasian population.

Methods

Cross-sectional data were analysed sex-stratified in 2555 men (mean age 60.4 years) and 2858 women (mean age 60.0 years) from the population study Tromsø 6. Associations were assessed by variance analysis and multivariable logistic regression of odds to have abnormal ALT. Risk factors included body mass index (BMI), waist-to-hip-ratio, blood pressure, lipids, glucose, glycated haemoglobin and high-sensitive C-reactive protein (CRP).

Results

Abnormal elevated ALT was detected in 113 men (4.4%) and 188 women (6.6%). Most CVD risk factors associated positively with ALT in both sexes except systolic blood pressure and CRP (women only), while ALT was positively associated with age in men when adjusted for CVD risk factors, P < 0.001. BMI predicted ALT in men (OR 0.94; 95% CI 0.88–1.00, P = 0.047) and women (OR 0.90; 95% CI 0.86–0.95, P < 0.001). A linear inversed association between age and ALT in men and a non-linear inversed U-trend in women with maximum level between 60 and 64 years were found.

Conclusion

This study confirms a positive relationship between ALT and CVD risk factors, particularly BMI. Age is not a major confounder in the ALT-CVD relationship, but separate sex-analyses is recommended in such studies.

Associations of serum liver enzyme levels and their changes over time with all-cause and cause-specific mortality in the general population: a large-scale national health screening cohort study

OBJECTIVES

To investigate the associations of the levels of liver enzymes, such as alanine aminotransferase (ALT), aspartate aminotransferase (AST) and gamma glutamyltransferase (GGT), at baseline and their changes over time with mortality.

DESIGN

Cohort study.

SETTING, PARTICIPANTS AND OUTCOME MEASURES

We analysed the data of 484 472 individuals from the National Health Insurance Service-National Health Screening Cohort (2002-2013). We used two exposure indices: (1) deciles of baseline ALT, AST and GGT levels measured in 2002 or 2003 and (2) deciles of changes in ALT, AST and GGT levels over a 4 year period (2002-2006 or 2003-2007). We constructed Cox models to evaluate the associations of these exposure indices with mortality (2008-2013).

RESULTS

We found non-monotonic dose-response associations between the baseline levels of ALT and AST and all-cause mortality. We also found a monotonic non-linear association between the baseline levels of GGT and all-cause mortality (10th decile: HR=2.05, 95% CI: 1.93 to 2.18). Compared with the ninth, sixth and fourth deciles of changes in ALT (8-13 U/L), AST (1 U/L) and GGT (-3 to -2 U/L) over time, respectively, the risks of all-cause mortality increased in both the higher and lower deciles of changes in the corresponding liver enzyme levels (10th decile: HR=1.36, 95% CI 1.24 to 1.48; 1st decile: HR=1.46, 95% CI 1.34 to 1.59 for ALT; 10th decile: 1.55, 95% CI 1.40 to 1.71; 1st decile: HR=1.53, 95% CI 1.38 to 1.69 for AST; 10th decile: HR=1.71, 95% CI 1.56 to 1.88; 1st decile: HR=1.67, 95% CI 1.52 to 1.84 for GGT). These non-monotonic dose-response associations remained when analyses were stratified by the medians or quartiles of the baseline liver enzyme levels.

CONCLUSIONS

The levels of liver enzymes at baseline and over time showed non-linear associations with mortality.

Elevated liver enzymes and cardiovascular mortality: a systematic review and dose-response meta-analysis of more than one million participants

Gamma glutamyl transferase (GGT), alanine aminotransferase (ALT), aspartate aminotransferase (AST), and alkaline phosphatase (ALP) are commonly used liver function markers. We performed a dose-response meta-analysis to investigate the association between liver enzymes and cardiovascular disease (CVD) mortality in prospective cohort studies. We conducted a systematic search up to April 2018 in Medline/PubMed, Scopus, Cochrane, and Embase databases. Combined hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated using a random-effects model as described by DerSimonian and Laird. Dose-response analysis was also carried out. Twenty-three studies with 1 067 922 participants reported association between GGT and CVD mortality and were included in our analysis. Pooled results showed a significant association between GGT and risk of CVD mortality (HR: 1.62; 95% CI: 1.47-1.78, P=0.001, P-heterogeneity=0.001) and it was HR: 0.87; 95% CI: 0.73-1.07; P=0.221, P-heterogeneity=0.028, for ALT. There was a direct association between baseline levels of ALP and AST/ALT ratio with CVD mortality (HR: 1.45; 95% CI: 1.11-1.89; P=0.005, P-heterogeneity=0.026, and HR: 2.20; 95% CI: 1.60-3.04; P=0.001, P-heterogeneity=0.540, respectively). Pooled results did not show any significant association between AST and the risk of CVD mortality (HR: 1.20; 95% CI: 0.83-1.73; P=0.313, P-heterogeneity=0.024). Moreover, there was a significant nonlinear association between GGT and ALP levels and the risk of CVD mortality (P=0.008 and 0.016, respectively). Our dose-response meta-analysis revealed a direct relationship between GGT and ALP levels and the risk of CVD mortality. High levels of GGT, ALP and AST/ALT were associated with an increased CVD mortality rate.

Usefulness of simple biomarkers at admission as independent indicators and predictors of in-hospital mortality in older hip fracture patients

INTRODUCTION

The data on predictive value of the routinely obtained preoperative biochemical parameters in hip fracture (HF) patients are limited. The aims of this study were to examine in older HF patients (1) the relationships between a broad set of routine laboratory parameters at admission and in-hospital mortality, and (2) evaluate the prognostic value the biomarkers and clinical characteristics (alone or in combination) provide to predict a fatal outcome.

PATIENTS AND METHODS

In 1820 consecutive patients with low-trauma osteoporotic HF aged >60 years (mean age 82.8 ± 8.1 years; 76.4% women; 65% community-dwelling) 35 laboratory variables along with 20 clinical and socio-demographic characteristics at admission were analysed. The validation cohort included data on 455 older (≥60 years of age) HF patients (mean age 82.1 ± 8.0 years, 72.1% women).

RESULTS

The mortality rate was 6% (n = 109). On univariate analysis 14 laboratory and 8 clinical parameters have been associated with in-hospital mortality. Multiple regression analyses determined 7 variables at admission as independent indicators of a fatal outcome: 4 biomarkers (albumin <33 g/L; alanine aminotransferase/gamma-glutamyl transferase ratio [GGT/ALT] >2.5; parathyroid hormone [PTH] >6.8 pmol/L; 25(OH)vitamin D < 25 nmol/L) and 3 pre-fracture clinical conditions (history of myocardial infarction, chronic kidney disease [GFR <60 ml/min/1.73 m²] and chronic obstructive pulmonary disease); the area under the receiver operating characteristic curve (AUC) was 0.75 (95%CI 0.70-0.80). The risk of in-hospital death was 1.6-2.6 times higher in subjects with any of these risk factors (RFs), and increased by 2.6-6.0-fold in patients with any two RFs (versus no RFs). The mortality rate increased stepwise as the number of RFs increased (from 0.43% -none RF to 16.8%- ≥4RF). The prognostic value of a single RF was low (AUC ≤0.635) but combination of 2 or more RFs improved the prediction significantly; AUC reached 0.84(95%CI 0.77-0.90) when ≥4 RFs (versus 0-1RF) were present. In the validated and main cohorts the number of predicted by 1, 2, 3 or ≥4 RFs and observed deaths were practically similar.

CONCLUSIONS

In HF patients, seven easily identifiable at admission characteristics, including 4 biomarkers, are strong and independent indicators of in-hospital mortality and can be used for risk stratification and individualised management.

Complex association of serum alanine aminotransferase with the risk of future cardiovascular disease in type 2 diabetes

BACKGROUND AND AIMS

We aimed to determine the prospective association between baseline serum levels of alanine aminotransferase (ALT) and the incident cardiovascular disease (CVD) in people with type 2 diabetes.

METHODS

In an open cohort setting, people with type 2 diabetes were followed for their first ever CVD presentation from 1995 to 2015. Statistical methods included Cox regression analysis for reporting of hazard ratios (HRs), artificial neural network modelings, and risk reclassification analyses.

RESULTS

We found a nearly constant CVD hazard with baseline serum ALT levels below the 30 IU/L mark, whereas baseline serum ALT levels ≥ 30 IU/L remained an independent predictor of lower CVD rates in patients with type 2 diabetes in the final multivariate Cox proportional hazards regression model (HR: 0.204, 95%CI [0.060-0.689], p_{for trend} value = 0.006). Age, male gender and fasting plasma insulin levels independently predicted baseline serum ALT ≥ 30 IU/L among the population cohort. Augmentation of serum ALT into the weighted Framingham risk score resulted in a considerable net reclassification improvement (NRI) of coronary heart disease (CHD) risk prediction in the study population (NRI = 9.05% (8.01%-10.22%), p value < 0.05).

CONCLUSIONS

Serum ALT could successfully reclassify about 9% of the population with type 2 diabetes across the CHD-affected and CHD-free categories. Overall, our findings demonstrate a complex and nonlinear relationship for the risk of future CVD by baseline serum ALT levels in patients with type 2 diabetes. Further studies are warranted to confirm whether this complex association could be translated into a clearly visible U or J-shaped figure.