ALT scores

[Fucsia63]

Any tghts on an ALT of 105 U/L please? Dr says it's 3x the limit.

[Hidden]

Has your doctor not said about further investigations?

[Worriesalot in reply to Hidden]

Mine was 35 doc said perfect?

[Hidden in reply to Worriesalot]

Absolutely perfect 😊

[Worriesalot in reply to Hidden]

Hope you are having good day Pam. Xxxxx

[Hidden in reply to Worriesalot]

Hey, not the best day today... having severe dizzy spells. I’m in hospital for two days this week so hoping for diagnosis. Hope you’ve had a good day lovely!! Xx

[Worriesalot in reply to Hidden]

Been swapping phones round just seen this. Hope you get better soon. Xxxxx

[Hidden in reply to Worriesalot]

Thank you 😊xxx

[Hidden]

Hello and welcome to the forum. A gentle reminder - community guidelines ask that results are not posted. A single abnormal result in itself does not prove or disprove anything. Results need to be considered in relation to how you are generally, any medical conditions, medications etc It might be worth you discussing the result with your GP, asking why they think it may be elevated and whether it can be repeated.

Here is a link to our booklet on liver blood test results and their meaning:

britishlivertrust.org.uk/in...

Do try and avoid DR Google !

regards

[Spoons20]

Mine is 11 and says on my report it should be below 40 but when I’ve worked out the ratio of that and my AST which is also low it indicates a higher than normal result I’m confused by it all

[Hidden in reply to Spoons20]

Check with your doctor as per BLT advice, but my understanding is the ratio is only relevant in the presence of an abnormal enzyme result(s). If both ALT and AST are within the normal range, then there’s no ratio of abnormality to assess.

[Str8jacket in reply to Hidden]

That's not accurate, though it's repeated here often and there seems to be a lot of confusion on this topic. Linked below is a good discussion of all the various diagnostic uses of the De Ritis ratio (often, regardless of the level of the enzymes).

An oversimplification--elevated enzymes indicate ongoing damage. The ratio (setting aside whether enzyme levels are elevated or not) can indicate a *cause* of ongoing or past damage. A cirrhotic who had Hep C or was an alcoholic can and often will have enzyme levels within the norm but may have a ratio different from the normal ratio range. People with no alcoholic liver damage will tend to have their ratio within a certain range, generally closer to 1-1.3 for males and 1-1.7 for females--other factors may affect an individual's ratio as well.

An elevated ratio (regardless of the enzyme levels) does not necessarily indicate the extent of harm. For a far better/detailed discussion, again, see below.

ncbi.nlm.nih.gov/pmc/articl...

[Str8jacket in reply to Str8jacket]

Indeed, and interestingly enough given your impression and the prevailing impression here, the authors note that the ratio is *less* useful when enzyme levels are abnormal. From the article:

"...there aren’t any generally accepted reference intervals for the ratio and indeed it is difficult to define ‘healthy’ limits for the ratio if its main application is when transaminases are abnormal."

[Hidden in reply to Str8jacket]

So I don’t have to read through the whole article on your link, could you point me to the paragraph where it says that ratio between alt and ast is significant even if both are in normal ranges?

[Hidden in reply to Hidden]

Have a look at the conversation below regarding the paper. I read it significantly differently to the way Str8jacket did, interpreting it as the de ritis ratio only being appropriate and diagnostically useful when you have an elevation in at least one of AST or ALT. It’s not applicable when there are no abnormal levels, unless the patient already has a clinically confirmed diagnosis of liver disease, at which point the ratio can have a prognostic purpose rather than a diagnostic one. Which is what I’d understood prior to reading the paper, and had previously replied to someone else on another thread earlier today.

[Hidden in reply to Hidden]

I have and read through it thoroughly and interpret it that same way as you completely. I think it’s frighting some people on here that are being told potentially there is something wrong with them when there isn’t so I’m going to confirm with my consultant when I see him and would advise anyone concerned about ratios within normal range to speak to their doctor and not read things on here as confirmation. Either that or call liver nurse at the trust who should be able to advise.

To be fair the link isn’t to be trusted anyway... it’s one study and what that one study may state, may differ on another study.

I don’t think misinformation helps anyone on here and I wouldn’t take anything as read unless it comes from the trust or a medical professional myself.

[Hidden in reply to Hidden]

And from personal experience whenever my liver results have been in normal range the doctors are very pleased. hence why the word “normal” is used to describe them.. 😉

[Hidden in reply to Str8jacket]

Interesting as ive never asked about AST as only my ALT was abnormal a number of times and was mentioned in a letter from my consultant as markedly high. I’d be interested to know what my ratio was between AST and ALT... I’m seeing my consultant soon and I’ll ask him what my ratio was at last test.

[Hidden in reply to Str8jacket]

Genuinely very useful and interesting paper, but can you point me to where it says that the ratio should be applied (and has diagnostic value) to levels that fall within established reference ranges? I’m just not seeing the same conclusions you are: I may well have missed it, but my reading did not demonstrate that it’s universally appropriate to diagnostically apply De Ritis for values not classed as abnormal. I’ll explain why.

I’m fairly new to liver issues, but not medicine and research generally, and I am aware that even in patients with cirrhosis both AST and ALT may fall within normal depending on the aetiology. However, I went through it twice, and my interpretation is that in normal serum value circumstances within diagnosed disease, such as those sometimes found with fibrosis in NASH, the De Ritis ratio then serves a primarily prognostic purpose over a diagnostic one, indicating the likely progression to cirrhosis. But it is very clearly written from a diagnostic and disease orientated standpoint, and states within the introduction that ‘Ideally all laboratories reporting abnormal ALT

should also report AST and calculate the De Ritis ratio’. If De Ritis has the same diagnostic value when both transaminases fall within accepted reference ranges, that would be highly incongruent with an explicit reference to abnormal ALT as a starting point, and the authors do then go on to talk about elevated levels throughout. The only deviation from focus on transaminase elevations is when they discuss the prognostic implications of the ratio as per the above regarding NASH progression. In the absence of a diagnosis, and with specific reference to AST and ALT within normal levels, this paper reinforces my previous understanding. Which was that De Ritis has no direct diagnostic value when the transaminases are both within normal, but it does have prognostic value when transaminases are within normal within the context of an otherwise clinically confirmed diagnosis of liver disease.

I’m not being difficult or argumentative, I genuinely would like to know if I’ve missed what you’re seeing. Knowledge is power, and I believe that when we learn, we grow.

[Str8jacket in reply to Hidden]

The quote I just cited specifically states that the ratio may be much less useful when the enzymes are out of the normal range.

Where the paper references elevated enzymes, it states so specifically. It would be an odd reading to imply the paper refers exclusively to elevated enzyme levels where it only references them in very specific portions, and where it does not assert the ratio is only useful when enzymes are elevated. There is no reasonable reading of it to imply that qualifier.

And again, you have the direct language quoted above.

[Str8jacket in reply to Hidden]

You make a valid point that I was not clear on the use of the ratio for diagnostic v prognostic purposes. It's probably true that ratio alone could not be used to diagnose liver disease or its etiology as you point out, and as I understood the article (no expert here either). However, it is useful in specific contexts even in the absence of elevated enzymes. If someone with a risky drinking history who has been abstinent for a year is worried about cirrhosis and comes in for a LFT, a De Ritis ratio of 2 might suggest there is underlying liver damage from alcohol even if the enzymes are within a normal range. At least that is my takeaway, in the context of ALD (leaving aside the other etiologies).

[Str8jacket in reply to Hidden]

I think the question of why the ratio can be interesting even in the absence of elevated numbers stems from the how--where it comes from. In a perfectly healthy individual, you'd expect the ratio to be within a certain range given that the production and clearance rates of AST and ALT are constants and fall within certain limits as well. If the ratio of the enzymes is off, even in the absence of ongoing injury leading to raised enzymes, the implication is there is an underlying issue driving that abnormality in production/clearance. That's my understanding, I may be way off.

[Hidden in reply to Str8jacket]

Reading it a third time and basing the conclusion solely on that paper, the purpose of the ratio is - and always has been - entirely to help determine aetiology, though, and not limited to ALD. With the caveat that I’m a layman, I would (broadly) agree that I can see where you’re coming from with the suggestion that De Ritis might be valid to indicate possible ALD cirrhosis in someone with normal ALT and AST following a period of abstinence, for example, but that doesn’t change that it’s not intended for that purpose, and that using it that way wouldn’t currently be accepted use as I understand things. Whatever other potential applications may exist, the accepted diagnostic value of De Ritis as per the paper is specifically to suggest the aetiology of abnormal transaminase elevations, with a secondary, prognostic purpose in those with an already clinically confirmed liver disease but normal transaminases. My understanding is that the prognostic application has emerged purely through the consistent aetiological use in the 70 years since the ratio was discovered. Taken in that context of current, accepted practice, De Ritis is not considered diagnostically in someone with normal transaminases, regardless of alcohol history. So we end up coming back to the original point of disagreement: based on the paper, and irrespective of any additional possibilities, it’s currently only deemed diagnostically appropriate and meaningful to calculate the ratio in the presence of at least one elevated transaminase. Any other diagnostic application would be purely theoretical, or perhaps only hypothetical, because it falls outside of the established purpose and - in the absence of any definitive evidence to the contrary - therefore remains unestablished and unproven to date. As the paper also points out, AST is still not considered a routine element of liver testing, it’s usually only done following other abnormal serum results such as ALT, even in those with appropriate history. That’s certainly been reflected in my own recent, personal experiences 🤦‍♂️

I’m post operative having had surgery on Tuesday, so I need to get some rest now, but with reference to your final reply, the one thing that immediately sprung to mind is that neither ALT or AST levels are solely indicative of hepatic dysfunction or disease, De Ritis ratio included. Amongst other things, I’ve found this evening that there are some really interesting papers on using the ratio purely as a predictor of oral squamous cell cancer prognosis and survival, along with in relation to cardiac arrest.

In any event, I agree it’s a really interesting subject, and I’ve ended up falling in far deeper than I intended! Would be interesting to see if any further diagnostic applications of the ratio (such as the one you suggested) are being studied in relation to LD.

[Str8jacket in reply to Hidden]

You make many great points, and I appreciate your insights. Gave me a lot to think about. Hope you're feeling better as well and recovering fast.

I'm not sure that the ratio should *not* be used, at least in part, to indicate cirrhosis or serious fibrosis in certain cases. Clinical trials re cirrhosis have used the ratio as a criterion for the inclusion of participants.

See clinicaltrials.gov/ct2/show...

Given that many folks who quit drinking and are at risk for severe liver damage have concerns about it, perhaps the ratio *should* be looked at more closely in those cases even if levels aren't elevated, if only to determine if more testing is needed.

I agree with you that it does not seem the ratio *is* being used for that purpose, and in general practices and among comments here you do see the statement repeated often that the ratio is meaningless when levels aren't elevated. That's hogwash--the question is how the ratio can be used. In the case of at risk patient history, an elevated ratio should probably not be dismissed so readily. In my case, the ratio was ignored even when I presented with symptoms(!); it tooks months of pleading and repeated bloodwork, and I was only prescribed lactulose and referred to hepatologists once my enzyme levels tripled and exceeded the norm.

I could have been started on therapies sooner (or even caught years ago when my liver was working). Instead, here I am, of course suffering/responsible for my own actions, but still not well served by docs who had my previous liver tests and never raised possible red flags to my attention, and ignored a clear indication of problems in the present moment.

C'est (or c'etait) la vie.

[Carp01]

I would wait for a 2nd test in a few months time and speak to your GP. One high result could be anything like painkiller, medication etc.

[Angelino123]

I just had an ALT test done and my result was 289. I'm terrified.