I just did my ast alt ratio. My ast is 19 my alt is 9 and when I calculate it. Tells me alcoholic liver Disease. Is this correct?
Ratio really nervous : I just did my ast... - British Liver Trust
Ratio really nervous
Written by
Linzenilss38
To view profiles and participate in discussions please or .
Read more about...
The ability to reply to this post has been turned off.
26 Replies
•
I think the ratio can be some indication in ALD only when they are both outside upper limits (AST, ALT). If both normal the ratio is irrelevant for ALD at least.
Thanks for the reply. When I did the calculator online it says indicative of cirrhosis and Ald.
This enzyme relationship has proved to be an area of debate here. Basically depending on which value is elevated and the EXTENT of that elevation, doctors can often get a pretty strong indication as to what liver disease they are dealing with.
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 type liver disease cannot be diagnosed by the pattern of elevation alone.
The size of elevation (described in multiples of the upper limit of normal) ALSO needs to be evaluated.
It is ONLY when the increase is above a certain threshold that the ratio can be considered diagnostic.
This threshold is different from person to person as even BMI can effect these two enzymes, along with age, sex and general health. Your levels would be considered low by most standards. Therefore the diagnostic value of the ratio is a moot point.
In fairness, I'm not sure this is a real debate or that anyone has posted any research suggesting the ratio is only relevant where the values of the enzymes are elevated. If this was a debate, one would expect it to be reflected in the literature.
In my anecdotal/unscientific experience, GP was completely oblivious to the relevance of the ratio. Unfortunate, as the ratio can be an early warning to problem drinkers (who can have many years of undiagnosed ALD before hitting alcoholic cirrhosis), and possibly could have been for me.
GIs and hep doc were aware of the ratio, but looked at it more as showing the cause of liver disease rather than the extent of it, and didn't give it too much attention in light of many other blood tests and imaging.
I’m guessing there is no straight answers
I think you got a few clear answers here. The ratio can be one piece of a constellation of data points used to uncover liver disease, including alcoholic liver disease if one is at risk. And no one here can diagnose you with liver disease or give you a clean bill of health, and certainly not based solely on AST and ALT values.
But yeah, aside from critical cases, liver health can be hard to assess. Even for docs who have much more info about a patient. Good luck to you. If you feel fine, don't worry too much, but do take care of your health.
That's a common, but apparently inaccurate, misconception. I was curious about this too. See links below if interested.
According to a wealth of research, an elevated AST/ALT ratio, even when the enzymes are within normal limits, can indicate alcoholic liver disease. There is a lot of research on this topic online--get your info on such questions from experts.
This study looked at enzyme levels for thousands of people:
aasldpubs.onlinelibrary.wil...
The authors found:
"In fact, the majority of individuals with asymptomatic advanced liver fibrosis or cirrhosis have transaminases within current reference limits.(8) In contrast, the AST to ALT ratio (AAR or “the De Ritis ratio”(9)) seems to correlate with the severity of liver fibrosis,(10) even when absolute transaminase values are within reference limits.(11, 12) "
A couple other sources:
ncbi.nlm.nih.gov/pmc/articl...
sciencedirect.com/topics/bi...
The ratio alone from one single test cannot be used to diagnose you, nor can anyone here diagnose you or give you an all-clear. Many tests, patient history, imaging, etc., are used to diagnose liver disease.
That said, abstention from alcohol, a healthy diet, and regular exercise can only be good for you, especially if you are concerned about your liver. If you have no symptoms, then even if you have early stages of alcoholic liver disease (pre-cirrhosis), you can give your liver an opportunity to heal itself. Best of luck to you.
Thank you. Every other test was normal even ggt. I had a normal ultrasound in March said it was normal size and no focal abnormalities. I carried on drinking though
If you feel fine, your image is clear, and your bloods don't otherwise indicate serious liver disease (and your history doesn't suggest you're at risk--usually takes over a decade of heavy drinking almost daily to develop serious disease), you're probably fine.
Listen to your docs (and your body), pamper your liver, and you may have no reason to ever revisit this forum. Unless you want to share stories of becoming an advocate for liver health awareness after quitting alcohol, I'm sure folks here would love to see something like that.
Also it is below also in the first link you posted
healthunlocked.com/api/redi...
"On the other hand, the performance of the AAR in discriminating advanced fibrosis or cirrhosis is inconsistent between studies,(10, 21) and discrimination performance in NAFLD and ALD is at best suboptimal.(17, 22) Adding to the controversy, an AAR >1 was observed in 36%-77% of apparently healthy adult volunteers lacking any signs of liver disease, which was dependent on weight and alcohol intake.(23) There is a paucity of studies on the role of the AAR for predicting incident liver-related events."
Also about BARD which uses that ratio:
mdcalc.com/bard-score-nafld...
"Doesn’t predict fibrosis but rules out (high sensitivity)"
So it seems it has very good NPV. So when AST/ALT < 1 is it very likely you do not have cirrhosis or severe fibrosis. But PPV is not so high. So when AST >1 it is not so likely (like for NPV) to have cirrhosis or severe fibrosis.
Now something from my own experience . I know someone who donated part of the liver. When she had lab test just before donation AST/ALT < 1. After some years she did some routine check up and AST/ALT = 1,18 (both normal range). I am almost certain she has no liver problem now. The answer I think can be that AST for example can change a litle not because of liver function. When both ALT, AST are low then it can reflect easy this ratio other then when both very high.
A ratio of 1.18 is pretty nearly 1, and according to the second linked article, for women a ratio of up to 1.3 is perfectly normal. It also bears keeping in mind that these thresholds are rough guides, there is nothing magical about a threshold of 1, any individual can have different baselines, and any one single blood test may not be perfectly representative of the underlying state of the liver.
I think the point all these articles make is that if the ratio shows up as significantly above 1 (as opposed to barely over), it may indicate alcoholic liver disease. Of course, patient history would be important too. That doesn't mean that alone the ratio is enough to diagnose anything, but rather it can serve as an important red flag.
Mine is 2 that’s why I’m worried
In light of the entire picture (no symptoms, clean bloods, short drinking history, etc etc), I wouldn't take that ratio alone and worry about cirrhosis. If you have some stage of liver damage, say F1 or F2, that can be reversed with clean living. A failing liver would let you know loud and clear.
Footnote 8 above comes from Elsevier.
This is what the professionals, not message board people like us, think about their studies.
theguardian.com/science/pol...
And the Elsevier article seems to be saying things its own footnotes do not say.
Footnote 9 is about Hepatitis A B C and D not Alcohol or Fatty Liver Hepatisis and elevated ratios.
sciencedirect.com/science/a...
Footnote 10 says that if they are ALT/AST are ABNORMAL (not within range) "Ideally all laboratories reporting abnormal...."
pubmed.ncbi.nlm.nih.gov/243...
Footnote 11 says that they have worked on a model to EXCLUDE advanced disease, not predict it. Their PPV or Positive Predictive Value is 2/3 wrong, 1/3 right. At least they admit it.
pubmed.ncbi.nlm.nih.gov/315...
Footnote 12 is a different article saying the same thing, that what is being researched is the ability to exclude.
pubmed.ncbi.nlm.nih.gov/233...
And so on and on. The fact is you can in theory have advanced disease with acceptable numbers, but the overwhelming amount of people do not. Worry when your numbers are greater than 2-3x over the upper limit. (And even then most people will be fine) since ALT numbers can fluctuate by 45% in the same day in the same individual and obesity can raise ALT by 50%. - Don't take my word for it - take the clinicians (third paragraph from the bottom).
clinlabnavigator.com/alanin...
The person posting the thread starting post should keep an eye on his health. He should also not stay awake worrying about being the rare exception, unless he takes pleasure in worrying about everything. Somehow I doubt that to be the case.
I have no idea what footnotes you're referencing. The Guardian article and viral hepatitis article you link don't seem relevant to the ratio in the context of chronic alcoholic liver disease fwiw, the topic of this thread. Also not sure what "clinlabnavigator.com" is about or its relevance. In any case didn't see any citations listed, any affiliation, or any other indication it's a credible source. I'll stick with peer reviewed research. And scores of commenters here have mentioned being diagnosed with cirrhosis with ALT and AST enzymes in reference ranges. It's very common. It's also a different question than whether a high ratio can indicate chronic alcoholic liver disease, which need not be cirrhosis, but can be an earlier and still-reversible stage, the ideal time to catch liver disease.
The takeaway here is that a high ratio for any one with a history of problem drinking should be used as motivation to quit harming the liver. It alone cannot diagnose anything, but can indicate liver damage caused by alcohol according to the studies even when absolute enzyme levels are low. Haven't seen it suggested that the ratio alone can diagnose anything, and no one is making that claim.
Also, high enzymes are present where there is active ongoing damage. They don't necessarily indicate the cumulative damage/state of the liver.
Agree that with a normal scan, no symptoms, no risky history, and otherwise normal bloods, there is probably nothing to lose sleep over. Quitting booze and adopting a healthy lifestyle, on the other hand, would not be a bad idea. For anyone who abuses alcohol.
Str8jacket,
I was just going to the links provided in what you cut and pasted.
Your cut and paste starts with the words "In Fact"
Then after the word "limits" in a box is the number (8)....next sentence after the word "ratio" is the number (9). Those numbers and the rest of the numbers lead to the "original sources" of how the authors you cut and paste came to their conclusions in the article they submitted.
The authors were the one's who raised the issue of the Viral disease and what I was saying to them is exactly what you are saying to me. Why are they citing Viral Hepatitis data in an article about Fatty Livers?
And the rest was just to emphasize that these things are much better at diagnosing who is healthy rather than who is sick.
Clinical Lab is run by a Dr and Professor who specializes in lab tests and their analysis.
clinlabnavigator.com/biogra...
My mistake, I thought you were addressing the merits of the Aberg paper and the point that the ratio is relevant in the context of possible chronic alcoholic liver disease even when enzymes are within normal ranges. I've not yet seen anything to contradict that.
Regarding the footnotes, if we must go off on that tangent:
Fn8- you make a genetic fallacy, and in any case the Guardian doesn't suggest Elsevier sources are not legitimate or credible necessarily--the criticism is about the paywall and open access. Many academic publishers use paywall, though some are moving away from that model. Also, are you suggesting THE LANCET Gastroenterology and Hepatology is not a credible source? Really??
Here's what the article from that LANCET journal concluded, by the way:
"RELIANCE ON ABNORMAL LIVER FUNCTION TESTS WILL MISS MOST PATIENTS WITH SIGNIFICANT LIVER INJURY."
Not yelling, just trying to make sure this point is not lost in my lengthy response--apologies for the length, by the way.
Fn9- the De Ritis article on hepatitis viruses is mentioned because that is where the name for the De Ritis ratio comes from. Simple.
Fn10- Your quote (cutoff, by the way) from the Botros article is irrelevant to the point we're discussing. That quote mentions that AST should be reported when ALT is abnormal, and is one small part of the intro. The article never suggests the ratio is only useful with abnormal enzyme levels. The full article discusses the ratio in many contexts, including many kinds of liver disease, when enzymes are elevated, and when they're not. In fact, the article points out that because of vitamin deficiencies, alcoholics may have depressed enzyme levels.
Fn11 and Fn12 are simply cited for the proposition that cirrhosis can be present in NAFLD patients with normal ALT levels. Those articles do not address the use of the AST/ALT ratio in chronic alcoholic liver disease patients. The predicitve values you cite do not address the De Ritis ratio in ALD, but wholly different models using many variables to predict an entirely different type of liver disease.
All of those statements aside, the ultimate point of the Aberg et al. paper (and others on the topic) stands--and elevated AST/ALT ratio in someone with problem drinking history can be an indicator of chronic liver disease. Let's not get distracted by any straw man--no one suggested anywhere that the ratio alone can be used to diagnose *anything.* But a chronic problem drinker with an elevated ratio, even with enzymes in normal ranges, would be well warned that s/he may be on a path to serious liver disease. That said, even the Aberg paper writes about hazard ratios, because nothing is determinative here, we're just talking probabilities.
If there are studies out there that address average enzyme levels in cirrhosis, it would be interesting to see them, but that question is ultimately not relevant to the question here, which is only whether the ratio has any relevance in chronic ALD when enzymes are within reference ranges. Again, the answer is yes, and though the ratio alone is not enough to diagnose anything, it *may* indicate a problem. Just like albumin, bilirubin, platelets, etc. alone cannot diagnose cirrhosis, but are relevant components of a bigger picture.
But simple ast/alt ratio (normal range) is according to even your links not the best tool to confirm cirrhosis or severe fibrosis (low PPV). So it is not the best trigger from scientific point of view. Let's imagine it would be used as some screen test in low probability population of liver problem (severe fibrosis). Then there would be many false positive results causing too many redundant further tests.
That's why we can for example test everyone with all normal liver tests with no symptoms. Yes we can probably find some asymptotic cirrhosis patient. But we cannot test everyone for everything that would be insane.
Changing the subject in one of article you provided there is something about dynamic AAR (dAAR). I think it is something new. Do you know how is it calculated?
AAR is just what the AST/ALT ratio is called in shorthand. How to remember - first letter of AST is "A", first letter of ALT is "A", first letter of ratio is "R" thus AAR)
We're getting way beside the point. No one ever suggested the ratio is the best tool to diagnose cirrhosis, or even that it can be used alone to do so. Only that, in the context of problem drinking history, a high ratio *can* be a sign of alcoholic liver disease despite enzymes in reference ranges. Exactly what the article in Hepatology Connections concludes, based on a study of tens of thousands of people.
correct
Ok. You reffered only to ALD. But even then not sure if PPV is very high. Do you have this value? Or sensivity or AUC? I mean from articles you linked.
I get the nervousness when checking! Mine was 1.43 and the calculator said “abnormal” in red.
However (I think) they were normal range so I TRY not to obsess too much. (Also clear ultrasound .. but results were same day so a bit skeptical)
Nope
Hi Linzenilss38 - I hope that the responses to your question have been helpful. Only a liver specialist can diagnose you with alcoholic liver disease. This diagnosis is made by monitoring bloods, scans and clinical examination/history taking of the patient. If you are in the UK and would like to chat further then our nurse led helpline is open Monday to Friday 10am to 3pm on 0800 652 7330. I would like to remind other members that although healthy debate is welcomed, it is not appropriate to hijack members threads by doing this. Whilst we acknowledge the importance and relevance of clinical research (and appropriate interpretation of this research) it is of equal importance to listen to your liver clinician's specific guidance.
Linzenilss38, I'll close this thread now but please post again if you would like further support from the forum members.
Warmest wishes
Trust10.
The ability to reply to this post has been turned off.
Not what you're looking for?
You may also like...
enzyme ratio
My AST ALT ratio is high. How do I lower it?
I have no symptoms at all, but reading about the...
Reversal of ALT & AST RATIO
blood results last week that my ALT is 38 and my AST is 47. My ratio works out as 1.24. My albumin...
AST/ALT Ratio
bloodwork looked fine. I always pay attention to the AST/ALT numbers due to my past heavy drinking...
Alt/AST ratio...
have alcoholic cirrhosis of the liver and my readings at my last blood test were...
ALT 45
AST 34...
Ast/alt ratio
about ratio he told him when ratio is 2.0 is when they worry about it. He did not ask if ast/alt...
AST/ALT Ratio
De-ritis ratio
AST/ALT Ratio
AST/ALT ratio 
liver Function test ratios and cirrhosis
