enzyme ratio : My AST ALT ratio is high... - British Liver Trust

British Liver Trust

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enzyme ratio

Genovia profile image

My AST ALT ratio is high. How do I lower it?

I have no symptoms at all, but reading about the ratio is worrisome

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35 Replies

If ALT and AST are in the normal range, forget the ratio - it is meaningless. Forget Dr. Google and Dr. De-Ritis.

Genovia profile image
Genovia in reply to Danubian

My AST is 1 point over the upper limit. My ALT is less than half the limit. That’s where my ratio concern comes in. I did do a boot camp class before my blood draw.could some exercise raise AST? My HDL is very high. Otherwise all my blood work is normal. Thanks for your thoughts.

Danubian profile image
Danubian in reply to Genovia

I think the ratio only comes into significance when the AST or ALT are WAY out of whack, so that 1 point above upper limit is pretty meaningless, but I am no doc.

Genovia profile image
Genovia in reply to Danubian

Really? I hope so.I was reading that if the numbers are greater than 2:1 it’s indicative of chirosis. Hope I’m wrong as the rest of my blood results are good.Thanks for your input.

Danubian profile image
Danubian in reply to Genovia

Indicative only and ONLY and I repeat ONLY when the numbers are well out of whack.

AyrshireK profile image
AyrshireK in reply to Genovia

It is only used when results are significantly above the upper limit of normal.

Quite a clear description of it all here:- verywellhealth.com/liver-en...

AST and ALT are measured in international units per liter (IU/L). The normal levels vary based on a person's body mass index (BMI) as well as the individual lab's reference value. Generally speaking, the normal reference value for adults is:

AST: 8 to 48 IU/L

ALT: 7 to 55 IU/L

The high end of the reference range is referred to as the upper limit of normal (ULN). This number is used to establish how elevated your liver enzymes are.

Mild elevations are generally considered to be two to three times the ULN. With some liver diseases, the level can exceed 50 times the ULN. Levels this high are described as deranged.


While it may seem that a high ALT is all that is needed to diagnose liver disease, its relationship to AST can provide valuable clues as to what exactly is going on and whether the issue is acute (occurring suddenly and progressing rapidly) or chronic (long-standing or persistent).

If the liver sustains an acute injury, you can expect to see a sudden spike in the ALT. On the other hand, if a liver disease is slowly progressing, the damage incurred by the liver will gradually affect other organs as well. As these organs are damaged, the AST will begin to rise.

This occurs with diseases like hepatitis C in which long-term liver damage will trigger an ever-expanding array of symptoms involving the kidneys, brain, eyes, skin, and joints (referred to as extra-hepatic symptoms).

This enzyme relationship can be described diagnostically with the AST/ALT ratio. This is a calculation that compares the levels of AST and ALT in your blood. Depending on which value is elevated and the extent of that elevation, doctors can often get a pretty strong indication as to what disease is involved.

What the AST/ALT Ratio Reveals

The AST/ALT ratio is important in so far as the pattern of elevation can tell a lot about the condition involved. Among the general guidelines used to diagnose liver disease:

An AST/ALT ratio of less than one (where the ALT is significantly higher than the AST) is suggestive of non-alcoholic fatty liver disease.

An AST/ALT ratio equal to one (where the ALT is equal to the AST) is suggestive of acute viral hepatitis or drug-related liver toxicity.

An AST/ALT ratio higher than one (where the AST is higher than ALT) is suggestive of cirrhosis.

An AST/ALT ratio higher than 2:1 (where the AST is more than twice as high as the ALT) is suggestive of alcoholic liver disease.

However, a disease cannot be diagnosed by the pattern of elevation alone. The magnitude of elevation described in multiples of the ULN also needs to be evaluated. It is only when the magnitude is above a certain threshold that the ratio can be considered diagnostic.

With normal bloods the AST:ALT ratio is NOT used diagnostically.


Trust1 profile image

Hi, A liver diagnosis depends on lots of diagnostic investigations including scans, blood tests and examinations. If you have concerns about any aspect of your blood tests we would suggest to discuss with your doctor.

Best wishes.

Thanks for the info. I’ll wait to see what my dr. says. Just trying to gather info and educate myself.

Str8jacket profile image
Str8jacket in reply to Genovia

That's the best course. I assume you're concerned about alcoholic cirrhosis if you're doing this research. If you're like me and are/were unable to have a glass or two a week like normal people, you should quit while you can. If you're asymptomatic, docs are unlikely to run more tests. They may not make much of anything. You still could be at F2-F3 and on your way to F4 (cirrhosis) if that is the direction you were headed. I knew I drank heavily but did not consider myself at risk--I drank because I wanted to/was bored, not because I couldn't stop. I was doing well professionally, I exercised, was youngish at mid 30s, etc etc. In hindsight, I was poisoning myself like a madman, at about 3-4 pints most days on average. Over enough years that's enough.

laura53923 profile image
laura53923 in reply to Genovia

Check out the British liver trust and the NHS for the best education and long term members with a lot of knowledge and experience such as AyrshireK and Richard-Allen. All you need are simple facts not figures with fancy names which is nothing more than gobbledygook causing unecessary worry.

All the best to you.


Liberty82 profile image
Liberty82 in reply to Genovia

I have been very concerned about my liver for several years, all tests have been normal, fibroscans, elf test, cat scan, ultrasound abd bloods. The only thing of concern (to me) was the de ritis which was 1.3, indicative of cirrhosis. However, when I spoke to my consultant about this is told me that the de ritis is only a tool when AST and ALT are not within normal range. He spoke at length about this and was very knowledgeable, he said he had recently written a paper on it. So what Danubian has already said is correct. The other poster I think suffers from severe health anxiety.

Genovia profile image
Genovia in reply to Liberty82

Thanks for your reply.I’m slightly out of normal range.... that’s why I asked. I’m away from home now and can’t actually be seen for a month. That’s why I was looking for info. Do you think 1 point above limit is no big deal? All other blood work is fine. I just have high HDL. I workout daily.

AyrshireK profile image
AyrshireK in reply to Genovia

1 point over doesn't even rate as elevated - when you see the piece I posted they deem anything up to two or three times the upper limit of normal as a MODERATE elevation. Both ALT and AST can be elevated due to physical exercise when the source of these enzymes in blood is muscle related rather than anything to do with the liver.

HDL is obviously cholesterol related so that obviously needs keeping an eye on by doctors.


People are left with a false reason for their anxiety thinking the ratio means anything at all when enzymes are within normal (clearly defined) levels.

MLB_77 profile image
MLB_77 in reply to Danubian

You seem to be coming off is pretty harsh in this thread. Searching through your previous posts you suffer a great deal of health anxiety yourself. So, surely you can relate (even though I see nothing too over the top in this thread pointing one toward feelings of health anxiety)

I don't want Genova to suffer anxiety like we did and you are.

"If one has a history of problematic drinking, the ratio can be a warning of existing damage (can be pre-cirrhotic) and should be used to warn oblivious problem drinkers even if levels are low."

I note the word "can". A warning is not a diagnosis. The word "warning" here means nothing - why - because cirrosis does not happen in weeks or months, so why have some people with perfectly healthy livers a high De-Ritis? Surely a little bit of fibrosis would be visible on MRT to confirm your progression theory. Fibrosis is visible on MRT my specialist told me. So are you telling me that De-Ritis is an indicator of liver damage progression? Well stone the crows! - we do not need any MRT, ultrasound, just check out da Big Dr-R ratio and Bob's your uncle we have a directly correlated diagnosis of F1, F2, F3 and F4. Amazing - you should write medical journals. The conclusion of De-Ritis being an indicator of the progression of liver damage will get you the Nobel prize for medicine.

The abstract of the first article mentioned no diagnosis of the first group, second group only somatic diagnosis - and no mention of elavated ALT and AST at all- second article relates to elevated enzymes. Do you every study these articles before citing them or even logically deal with your thesis. Still waiting for you rebutal as to why, if it is a warning, no fibrosis is found in progression proving your theory.

"Among biochemical abnormalities De Ritis Ratio (AST/ALT ratio) is more sensitive during any phase of the disease. " We are talking about people already with disease not diagnosis. "Now stop bothering me." I don't take orders and certainly not from you.

str8jacket, which medical establishment did you actually educate yourself in? Clearly it has fallen short because your quest for a cirrhosis diagnosis continues. Begs the question, why do you want a cirrhosis diagnosis and can’t you accept what qualified doctors are saying?

We will we will rock you !!👏

Isn’t that a contradiction? “The usefulness of the De Ritis ratio as a diagnostic tool has to be evaluated against those who had a confirmed disease”. Err, if you have a confirmed disease, what do you need a diagnostic tool for?

I don’t need to look at anything, my doctors told me that not only did I need to stop drinking but I also required a liver transplant, confirmed by a biopsy.

They strongly recommend that I follow all their advice, which I did. I am coming up for my third transplant anniversary.

And one more thing, my health anxiety was due to very painful Pterygoid Hamulus Bursitis which not even professors could diagnose at the time. PHB ain't no duckwalk. But in contrast to you I have defeated my anxiety.


🤔🤔🙄🙄 my brain hurts 🤣🤣🤣

Danubian profile image
Danubian in reply to laura53923

As I said "here we go again"🙄😘

Oh yes TT is well and very clever

Grab the popcorn, it’s handbags at dawn!! I don’t understand any of the above!

laura53923 profile image
laura53923 in reply to deanw41

🤣 don't fret Dean.... the post will be closed for further comment before long. 🤞

Danubian profile image
Danubian in reply to laura53923


You speak to the spouses of severely ill alcoholics... there is absolutely no chance that their husbands would comprehend it. The only thing on their mind is where their next drink is coming from.

Sorry ... could we recap by a couple of months?? So you were drinking a few pints a night for 15 years and are 37. No tests or doctor's or specialist's diagnosis of cirrhosis, but you have spent god knows how long, googling and you have diagnosed yourself with end stage liver disease by a bunch of meaningless figures and no real symtoms of liver disease at all?? Wow !! You have absolutely no idea at all what being alcohol dependant (alcoholic in American speech) and having alcoholic liver disease is like have you?? If only l could take you through the last 4 years of my husbands life and the 10 plus years prior to that !! You really wouldn't be wishing it on yourself much less inflicting your rediculous theories on others.

Oh and a trip to ICU is a must !

The Trust folks are spot on here, as always. You cannot use the ratio *alone* to diagnose anything. On the other hand, the fact that the AST and ALT values are in the normal range cannot rule out cirrhosis. Plenty folks here and other liver disease forums mention how they had liver disease even with seemingly normal blood results--even imaging tests have missed serious liver disease. Any inquiry into your case would start with your history and symptoms. If you drank almost daily for many years you'd be at a much higher risk than if you merely drank occasionally, assuming alcohol is your risk factor. How much do/did you drink?

That said, the De Ritis ratio can be used to help identify the nature of liver disease even when the values within normal ranges. A ratio of 2.0 is elevated, and certainly well beyond the expected norms. Caveat--a normal range for females is higher than for males. And remember, liver disease doesn't necessarily mean cirrhosis and death--if you catch it in early stages, you can stop the progression. For a comprehensive discussion of the use of the ratio and where it comes from (has to do with the rate at which a healthy liver clears AST and ALT, whether or not something in the moment is causing an elevation of the enzymes), see the linked article.




Researchers even use the ratio on its own to indentify cirrhotics for clinical trials.


If you have no symptoms but you're worried about your drinking, this would probably be a good time to stop. I had a liver blood test 5 years ago--all levels within normal ranges, though the ratio was elevated. Nothing was mentioned, only saw the results recently. Same thing this past November. Docs said nothing, I didn't change my behavior, I assumed there was no way I could be doing serious liver damage at my age and rate of drinking (very high, but not as high as some folks you hear of, i.e. not waking up to drink hard liquor, not drinking to blackout), and now my liver is starting to fail.

Trust10 profile image

I am closing the above thread due to the nature of some of the comments above. Healthy discussion and debate is to be encouraged - bullying and unkind comments shall not be tolerated in this forum.Trust10.

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