Estimation of normal values of serum transaminases based on liver histology in healthy Asian Indians

Association of De Ritis Ratio with Prognosis in Patients with Coronary Artery Disease and Aminotransferase Activity within and outside the Healthy Values of Reference Range

BACKGROUND

The aspartate aminotransferase (AST) to alanine aminotransferase (ALT) ratio (De Ritis ratio), obtained from AST and ALT activities in the healthy range, has not been studied in association with mortality.

METHODS

This study included 3392 patients with stable coronary heart disease and aminotransferase activity in the reference range. Patients are categorized into two groups: a group with AST and ALT activity in the healthy range (n = 1697), and a group with AST and/or ALT activity outside the healthy range but in the reference range (n = 1695). The primary endpoint was all-cause mortality at three years.

RESULTS

The De Ritis ratio (median 5th-95th percentile] was 0.94 [0.61-1.41] in patients with AST and ALT in the healthy range and 0.93 [0.45-1.96] in patients with AST and/or ALT outside the healthy range (p = 0.700). At three years, there were 86 deaths in patients with AST and ALT in the healthy range: 27 deaths (3.9%) in patients with a De Ritis ratio ≤median, and 59 deaths (8.2%) in patients with the De Ritis ratio >median (adjusted hazard ratio [HR] = 1.16, 95% confidence interval [CI] 0.94 to 1.42; p = 0.159); in patients with AST and/or ALT outside the healthy range, there were 148 deaths: 49 deaths (6.6%) in patients with a De Ritis ratio ≤median, and 99 deaths (14.1%) in patients with De Ritis ratio >median (adjusted HR = 1.27 [1.09-1.48], p = 0.002), with both HRs calculated per unit higher values of the De Ritis ratio.

CONCLUSIONS

The De Ritis ratio obtained from AST and ALT activity in the healthy range was not independently associated with higher risk of mortality. The De Ritis ratio obtained from aminotransferase activity outside the healthy range (but still in the reference range) was independently associated with the risk of mortality.

Liver Stiffness Values in Persons with Normal Histology

Background and aims

Most studies to date have focused on liver stiffness measurement (LSM) in patients with different chronic liver diseases, and normal LSM is defined based on normal liver function tests or the absence of fibrosis. Very few studies have defined LSM based on completely normal liver biopsies. The current study was done to define the distribution of LSM values in individuals with normal liver biopsies.

Methods

All prospective liver donors presenting to Medanta, the Medicity hospital between September 2020 and September 2021 fulfilling the eligibility criteria were included in this study.

Results

A total of 63 donors (36 females and 27 males) were included in the study, 37 (58.7%) donors had normal liver biopsies, and 26 (41.2%) donors showed the presence of non-alcoholic fatty liver disease. LSM values in the normal liver histology group were 5.01 ± 1.99 kPa by the M probe and 5.34 ± 2.25 kPa by the XL probe. Even though the correlation was weak (r = 0.29, P = 0.03), M probe LSM correlated positively with body mass index. There was a good correlation between the LSM measured by the M probe and the XL probe (r = 0.73, P = <0.001).

Conclusions

LSM value in the biopsy-proven normal liver histology group was 5.01 ± 1.99 by the M probe and 5.34 ± 2.25 by the XL probe.

Diagnostic Accuracy and Optimal Cut-off of Controlled Attenuation Parameter for the Detection of Hepatic Steatosis in Indian Population

BACKGROUND AND AIMS

Ultrasound of the liver is not good to pick up mild steatosis. Controlled attenuation parameter (CAP) evaluated in transient elastography (FibroScan) is widely available in India. However, data regarding the diagnostic accuracy and optimal cut-off values of CAP for diagnosing hepatic steatosis are scarce in Indian population. MRI-PDFF is an accurate technique for quantifying hepatic steatosis. Thus, this study examined the diagnostic accuracy and optimal cut-off values of CAP for diagnosing steatosis with MRI-PDFF as reference standard.

METHODS

A total of 137 adults underwent CAP and MRI-PDFF measurements prospectively. A subset of participants (n = 23) underwent liver biopsy as part of liver transplantation evaluation. The optimal cut-off values, area under the receiver operating characteristic (AUROC) curves, sensitivity, and specificity for CAP in detecting MRI-PDFF ≥5% and ≥10% were assessed.

RESULTS

The mean age and body mass index (BMI) were 44.2 ±10.4 years and 28.3 ±3.9 kg/m², respectively. The mean hepatic steatosis was 13.0 ±7.7% by MRI-PDFF and 303 ±54 dB/m by CAP. The AUROC of CAP for detecting hepatic steatosis (MRI-PDFF ≥5%) was 0.93 (95% CI, 0.88-0.98) at the cut-off of 262 dB/m, and of MRI-PDFF ≥10% was 0.89 (95% CI, 0.84-0.94) at the cut-off of 295 dB/m. The CAP of 262 dB/m had 90% sensitivity and 91% specificity for detecting MRI-PDFF ≥5%, while the CAP of 295 dB/m had 86% sensitivity and 77% specificity for detecting MRI-PDFF ≥10%.

CONCLUSIONS

The optimal cut-off of CAP for the presence of liver steatosis (MRI-PDFF ≥5%) was 262 dB/m in Indian individuals. This CAP cut-off was associated with good sensitivity and specificity to pick up mild steatosis.

Upper Normal Limits of Serum Alanine Aminotransferase in Healthy Population: A Systematic Review

BACKGROUND

Measuring serum alanine aminotransferase (ALT) enzyme is a routine clinical test commonly used to evaluate abnormalities in the body in general, and in the liver function in particular. Higher ALT levels are associated with some metabolic disorders. The upper limit normal (ULN) is considered as a reliable threshold for the definition of high ALT.

OBJECTIVES:

To assess the existing evidence on the ULN for ALT in the general population.

DATA SOURCE:

PubMed (Medline), EMBASE, Scopus, and Web of Science (ISI) were searched using a specified search strategy.

ELIGIBILITY CRITERIA:

We collected documents published from 1980 to 2018 in the English language, focusing on human samples at the population level and extracted the data after qualitative evaluation.

METHODS

We conducted this study in accordance with the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. We used specific search terms and their combinations to find documents from relevant databases. We used a snowballing approach to find documents not captured in the main phase of the search. Two authors separately conducted the search, screened the articles, and selected documents that were qualified for data extraction based on the defined inclusion criteria. Finally, data extraction was conducted by two authors using PRISMA checklist. Reported ULNs for ALT and 95% confidence intervals (CIs) were documented in previously developed datasheets.

RESULTS

Out of 15242 studies, 47 articles were included for data extraction and analysis. Data were sparse and lacked the consistency to precisely estimate ULN for serum ALT. The ULN of ALT was significantly diverse across various geographical locations and sexes. The lowest value of ULN for ALT was 19 IU/L in Chinese children (age range: 7 to < 10 years), and the highest value of ULN for ALT was 55 IU/L in children from Ghana aged < 5 years.

LIMITATIONS:

The main limitation of the current systematic review was the scarcity of the reported measures for ULN of ALT.

CONCLUSION

Based on the results of the current systematic review, it is suggested that the normal range of ALT be redefined, but this redefinition should be done according to the localized data. In order to redefine the ULN for ALT, regional differences, methods used in ALT measurements, and ULN determination should be considered.

Screening of Cardiovascular Disease in Nonalcoholic Fatty Liver Disease: Whom and How?

Nonalcoholic fatty liver disease (NAFLD) is the most common liver disease worldwide. Patients with NAFLD are at a higher risk of developing cardiovascular disease (CVD). In fact, CVD-related mortality is more common in patients with NAFLD in comparison to liver-related mortality. This association is related to the common metabolic risk factors such as obesity, dyslipidemia, diabetes, and hypertension shared by both NAFLD and CVD, and also there is independent association of NAFLD with CVD because of risk factors such as insulin resistance, systemic inflammation, and atherogenic dyslipidemia. While there is abundant literature on association of NAFLD with CVD, there is sparse literature regarding the screening for CVD in patients with NAFLD. In the current review article, we discuss as to which patients with NAFLD to screen and how to screen for CVD.

Redefining the Normal Values of Serum Aminotransferases in Healthy Indian Males

BACKGROUND

The normal range for Aspartate and Alanine Aminotransferases (AST and ALT) levels (<40 IU/L) were set in 1950s. Recent data from certain countries suggest lower levels of AST and ALT. Aim of the study was to redefine the normal values of aminotransferases in healthy Indian adults.

METHODOLOGY

In a cross sectional prospective study, 1002 blood donors were evaluated to isolate a healthy cohort. Four and 9 subjects positive for HBsAg and anti-Hepatitis C Virus (HCV) respectively and three females were excluded. 986 male subjects were evaluated for levels of serum aminotransferases.

RESULTS

Of total 986 subjects (Group I), 543 (55.1%) had fatty liver on ultrasound [15 (1.5%) alcoholic fatty liver and 528 (53.5%) Nonalcoholic Fatty Liver Disease (NAFLD)]. Median AST and ALT in total group (Group I) were 27.69 (Interquartile Range (IQR) 22.33-37.04) and 34.19 IU/L (IQR 23.12-54.87) and in NAFLD (Group II) were 35.67 (IQR -27.49-47.43) and 50.36 (IQR 37.70-76.58) IU/L. Of remaining 443 subjects without fatty liver, 288 had one or more components of metabolic syndrome. Out of 155 patients with no fatty liver and no component of metabolic syndrome (Group III), 103 subjects had normal Body Mass Index (BMI) and normal cholesterol and Low Density Lipoprotein (LDL) (Group III_B). Median AST and ALT in Group III_B were 22.56 (IQR 20.23-26.91) and 21.36 (IQR 17.49-27.21) U/L respectively with a 95th percentile of 34.28 and 36.57 U/L for AST and ALT, respectively.

CONCLUSION

Levels of AST and ALT in healthy men are lower than the conventional values in India.

Biopsy Proven Fibrosis in Non-Alcoholic Fatty Liver Disease: An Analysis of Risk Factors

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is emerging as an important cause of liver disease in India. NAFLD is characterized by hepatic steatosis in absence of a significant alcohol use or other known liver disease. Non-alcoholic steatohepatitis (NASH) is a progressive form of NAFLD which deserves particular attention because it is more prone for development of fibrosis. Liver biopsy is the gold standard for diagnosis of NASH by evaluating necroinflammatory activity and stages of fibrosis. The aim of the study was to analyze liver biopsy specimens and identify risk factors associated with fibrosis in patients of NAFLD in eastern coastal India.

METHODS

A total of 216 subjects with fatty liver in ultrasonography (USG) were selected for needle biopsy. Those NAFLD cases showing fibrosis in biopsy were analyzed for risk factors association.

RESULTS

Definite NASH was diagnosed in 50 (23.14%), borderline NASH in 66 (30.55%) and not NASH in 100 (46.39%) of cases. Those patients with fibrosis (22%) were taken as cases and those without fibrosis (78%) were taken as controls for risk factor analysis. Age > 40 [odds ratio (OR) 2.01 (1.09-4.04)], female gender [OR 2.74 (1.24-6.05)], body mass index (BMI) > 23 [OR 15.36 (4.59-51.37)] and moderate fatty change in USG [OR 1.89 (1.01-3.62)] were observed as risk factors for progression to fibrosis in NAFLD cases.

CONCLUSION

Older age, females, obesity and moderate fatty liver on USG are risk factors for development of fibrosis in patients with NAFLD. Patients with these risk factors should be selected for liver biopsy and to be kept for close follow-up.

Dapagliflozin and Empagliflozin Ameliorate Hepatic Dysfunction Among Chinese Subjects with Diabetes in Part Through Glycemic Improvement: A Single-Center, Retrospective, Observational Study

INTRODUCTION

Sodium-glucose co-transporter 2 inhibitors (SGLT2i) improve hepatic dysfunction, although studies focusing on their underlying mechanisms are lacking, especially ones on dapagliflozin and empagliflozin. Here, we investigated the relationship between amelioration of hepatic dysfunction and improvement in various metabolic parameters among Chinese subjects with type 2 diabetes (T2DM).

METHODS

This was a single-center, retrospective, observational study that involved 115 Chinese participants with T2DM treated with either dapagliflozin or empagliflozin for at least 6 months between July 2016 and February 2017.

RESULTS

Of the 115 participants included in this study, 69 received dapagliflozin and 46 received empagliflozin. After 6 months of treatment, all patients showed significant improvements in body weight (BW), systolic blood pressure (SBP) and fasting glucose (FG) and glycated hemoglobin (HbA1c) levels. All participants also showed a significant reduction in serum alanine aminotransferase (ALT) levels, from 40.3 ± 28.0 to 29.0 ± 14.1 U/L (p < 0.001). Pearson's correlation analysis revealed a positive correlation between the reduction in ALT levels after treatment with the respective SGLT2i and changes in FG (p = 0.014) and HbA1c (p = 0.043) levels over 6 months, but not with changes in BW and SBP. Multiple linear regression analysis revealed that the reduction in serum ALT levels was independently associated with changes in both HbA1c and FG but not with the changes in the other clinical variables, including BW.

CONCLUSIONS

Dapagliflozin and empagliflozin improved both metabolic and hepatic dysfunction as a class effect. The amelioration of hepatic dysfunction was mediated partly through an alleviation of hyperglycemia and possibly through an improvement in insulin resistance, independent of BW.

Optimal cut-off value of alanine aminotransferase level to precisely estimate the presence of fatty liver in patients with poorly controlled type 2 diabetes

Optimal cut‐off value of ALT level to precisely estimate the presence of fatty liver was as low as 28.0 U/L. We should consider the possibility of fatty liver even when ALT level is within normal range in subjects with poorly controlled type 2 diabetes.

Prediction of nonalcoholic fatty liver in prospective liver donors

BACKGROUND

Metabolic risk factors should be important in addition to imaging for prediction of steatosis in prospective liver donors.

MATERIALS AND METHODS

The study group included all prospective liver donors who had a liver biopsy during workup. Risk factors of metabolic syndrome were analyzed, and body mass index (BMI) ≥25 kg/m² was used in place of waist circumference. Three BMI cutoffs (25, 28, and 30 kg/m² ) and two CT-measured liver attenuation index (LAI) cutoffs (<5 and ≤10) were used for steatosis assessment of ≥5%, ≥10%, and ≥20%.

RESULTS

Of the 573 prospective donors (307 females), 282 (49.2%) donors had nonalcoholic fatty liver (NAFL). When donors with NAFL were compared with donors having normal histology, multivariate analysis showed BMI, ALT, triglycerides, and LAI as significant predictors of NAFL. BMI ≥25 kg/m² and LAI <10 were better cutoffs. The presence of ≥2 metabolic risk factors had better sensitivity than CT-LAI for the presence of NAFL and ≥20% steatosis (58% and 54% vs 47% and 22%, respectively, for CT-LAI ≤10). The presence of LAI >10 and <2 metabolic risk factors predicted <10% steatosis with 96% specificity and 92% positive predictive value.

CONCLUSION

The presence of ≥2 metabolic risk factors improves sensitivity of CT-LAI for prediction of donor steatosis.

Nonalcoholic fatty liver is not associated with incident chronic kidney disease: a large histology-based comparison with healthy individuals

BACKGROUND

Nonalcoholic steatohepatitis or fibrosis is associated with the increased prevalence of impaired kidney function. It is not known whether nonalcoholic fatty liver (NAFL), which is steatosis without inflammation or fibrosis, is associated with renal impairment as these individuals are not candidates for liver biopsy.

MATERIALS AND METHODS

The study group included all liver donors who underwent a preoperative liver biopsy for various reasons. NAFL was defined as more than 5% hepatocytes having steatosis and no changes of steatohepatitis and/or fibrosis. Individuals with NAFL were compared with individuals with normal liver histology. Estimated glomerular filtration rate was calculated with the Modification of Diet in Renal Disease and Chronic Kidney Disease Epidemiology Collaboration methods.

RESULTS

The mean age of the study group was 35±10.3 years and the mean BMI was 26±3.2 kg/m. A total of 187 adults having NAFL (80 men) were compared with 186 (88 men) individuals with normal liver histology (controls). Individuals with steatosis had significantly higher BMI (26.8±3.5 vs. 25.5±3.8 kg/m, P<0.001) and serum alanine transaminase levels (33.8±13.3 vs. 27.2±9.8 IU/l, P<0.000). There was no significant difference in the estimated glomerular filtration rate between the normal histology group and the NAFL group with Modification of Diet in Renal Disease (115±21.8 vs. 114.4±23.2 ml/min, P=0.803) and Chronic Kidney Disease Epidemiology Collaboration methods (113.6±14.8 vs. 113±14.7 ml/min, P=0.668). There was no significant difference as regards serum creatinine (0.73±0.16 vs. 0.74±0.16 mg%, P=0.536), proteinuria (P=0.121), diabetes (1 vs. 4, P=0.372), and hypertension (2 vs. 6, P=0.174) in individuals of both groups.

CONCLUSION

Presence of NAFL does not adversely affect renal function.