There is to much confusion here on this site about ast/alt ratio. Some say ratio does not matter if both ast and alt are normal. Some say even if both normal ratio matters which is it I say stop answering unless you really know because I talked to someone today that said they asked there specialist about ratio he told him when ratio is 2.0 is when they worry about it. He did not ask if ast/alt were normal does ratio matter. The ones saying that ratio does not matter when both ast and alt are normal dont matter prove it.
Ast/alt ratio : There is to much... - British Liver Trust
Ast/alt ratio
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Chris884
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I got tests recently and had AST of 21 and ALT of 10. I am not going to spend time worrying about it...though of course I have followed all the posts here and done my expert research (obviously joking I am no expert..just the normal google stuff). Worrying doesn't help anything though.
One interesting thing I'd like to point out is that reading sites say that ANY ratio is telling you that you have some sort of liver disease, which obviously doesn't make ANY sense because that would mean everyone does. That leads me to believe they really only matter if they are elevated. Would an AST of 21 and an ALT of 10 really be worse than an AST of 21 and an ALT of 200? Anyway, like 7 years ago I had an AST of 23 and an ALT of 8. I mostly felt fine then and now.
The below is what one site linked here said...which is what leads me to believe it HAS to be elevated (since if it didn't, this would mean that all results for anyone, would be suggestive of some sort of liver disease), plus it notes it at the end.
"The AST/ALT ratio is important insofar as the pattern of elevation can tell a lot about the condition involved.1 Among the general guidelines used to diagnose liver disease:2
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."
verywellhealth.com/liver-en...
Furthermore, if there was an alarm to be had, there would have to be some sort of red flag on blood test results ....you know, at least from somewhere around the world..when you have the AST>ALT ratio...especially when it is above 2. But I haven't seen that anywhere, except one person mentioned insurance was flagged when they had a 2.6 ratio when getting insurance..I am unsure if that person had results out of range or not.
"reading sites say that ANY ratio is telling you that you have some sort of liver disease..." I think that's misreading those guides. I understand them to mean that IF liver disease is diagnosed (however that may come about-symptoms, scans, etc.), the ratio, whatever it is, can be used to identify the cause of liver disease, NOT that any ratio whatsoever indicates liver disease. Everyone has some sort of ratio, even perfectly healthy people.
On the other hand, in the absence of a diagnosis, a ratio well above 1 (not, say, 1.2), can suggest liver disease, but alone cannot be used to diagnose it. One of the reasons is that the liver is not the only source of AST. It seems though that someone *who is at risk* of liver disease (especially alcoholic liver disease) should be wary of a ratio well above one. It may be an early warning before the disease becomes symptomatic.
Ultimately, anyone truly interested in the AST/ALT ratio would be best served in searching out high-quality peer reviewed research on the topic (there is quite a bit out there), and not asking random message board users to interpret this one variable. I certainly would never take the word of some stranger online with a moniker like "Str8jacket," and I can't recommend anyone else do so.
Also, know that GPs may be unfamiliar with the concept entirely, which may be one reason liver disease is rarely caught early.
From The Lancet Gastro. and Hep.:
pubmed.ncbi.nlm.nih.gov/284...
"Reliance on abnormal liver function tests will miss most patients with significant liver injury."
What if you stopped drinking years ago and still have a high ratio? All other labs normal
Not worth worrying about if no symptoms and no diagnosis.
I would agree that there is nothing to accomplish with worrying--stick to a liver healthy lifestyle and you'll do as well as you can.
Knowing what I know now, in that situation (assuming chronic heavy drinking and a truly elevated ratio--not 1.1) I would assume *some* liver damage, not necessarily cirrhosis, and do everything I could to treat my liver well. And above all, enjoy life.
But after years wouldn’t it have healed? Cirrhosis is the only stage that is reversible.
Whilst the liver has a great ability to repair itself from some damage over time if cirrhosis occurs then it is unlikely to ever fully heal. Cirrhosis is not generally reversible you may see some improvement but once the liver is cirrhotic that is considered end stage liver disease. Fibrosis at the earlier stages is deemed reversible but cirrhosis not fully so.
How many years of drinking? How much drinking? How many years of abstinence? It may take many years to get to even F2 or F3 levels of liver damage, and may take years for the damage to reverse if there is reversal. Also, other things can cause AST to be higher than ALT. AST doesn't come from only the liver. Thus, the ratio alone cannot diagnose anything, even if it can suggest liver damage from alcohol in some cases.
Again, if you feel fine, have great bloods, etc. and you stopped harming your liver, there is really no reason or point in worrying. If you have a history of abusing your liver, treat it well, and enjoy your life.
I am trying .hoping that as long as I don’t drink again I’ll remain this way for a long time. Hard not to google and think the worst though.
in reply to Anners6010
Avoid googling Anners. Check out the British liver trust website for the best, most realiable information you can get. Stay positive and enjoy your life.Best wishes
Laura
in reply to Anners6010
Sadly no, cirrhosis is not reversable but by eating healthily, keeping as active as possible & avoiding all toxins such as alcohol and cigarette smoking you can live for a good number of years. Cirrhosis comes with many symptoms which can be treated with medication, others require hospital treatments as and when the occur. It is a very difficult disease to live with for both the sufferer and the carer as both Katie and her husband can testify but are living the best life they can together for as long as they can.
Anners6010 in reply to
Thank you Laura. I understand that- I wrote my comment wrong. I meant to say since I have years without a drink, and ratio meant anything it probably is cirrhosis since it’s NOT reversible. Is there any info available as to how long one can stay compensated for?
in reply to Anners6010
That l don't know. I would imagine it varies from person to person. Katie is probably one of the most knowledgeable people here where cirrhosis is concerned and may be able to give you the most encouraging info.The most important thing is to continue to look after yourself the way you are and avoid stress and worry it serves no purpose.
Take care. All the best to you
Laura x
I've seen you post that link and other old ones multiple times and read them multiple times. No need to post again. It's clearly evident that elevation, symptoms, etc, is the first thing to look at, and then once a probable liver problem is there, then consider the ratio. Many have normal labs, even with Cirrhosis, so using those alone are worthless, and the mere fact that articles say ANY ratio could suggest some type of liver disease, further proves it so. I think many of us have been discussing with people, doctors, etc, for a much longer period, and have experience WITH Cirrhosis, Fibrosis, etc, and what the ratios were. And if you were really concerned with studies, would know that the vast majority say it takes 15 to 20 years of HEAVY drinking to develop alcoholic cirrhosis, though it is possible for it to take shorter times. I think most of us who developed alcoholic cirrhosis spent 15-20 years drinking heavily...like 10-15 drinks every day (or near every day) for 15-20 years, and often at that point still have minimal symptoms. I did for near 20 years at that level...and drinking what I think is your level about 10 before that (if your level is 5-7 drinks 3-5 times a week).
We may be talking across each other, I'm not sure we disagree all that much. And I'm not debating the conclusions in the articles, they speak for themselves. Everyone is better off going directly to the research and not message board commenters to learn about the application of the ratio in the absence of elevated enzymes.
But again, NO ARTICLE states that ANY ratio indicates liver disease. Only that where liver disease *is confirmed* the ratio (high, low, close to one) can help show the cause.
It is a separate, and different, point to note that an elevated ratio in the absence of a diagnosis may on its own suggest (not diagnose) alcoholic liver disease, because a healthy body/liver will tend to produce and clear AST and ALT at rates that result in a close to 1:1 ratio in the blood. Something is probably off if that ratio is significantly and regularly off.
As far as other studies you allude to, feel free to share them. I'm always ready to learn, and it's not a cause for offense if someone disagrees with me and supports their disagreement. Context/tone is often lost on these boards, and some folks take debate personally-hope nothing I wrote offended you. Nothing was meant to offend, I was addressing a purely empirical question.
The real value to a wider appreciation of the AST/ALT ratio in alcoholic liver disease would be for more docs to use it to spot problem drinking *before* someone gets to cirrhosis. It's a bit late after that. Your point about looking to elevation and symptoms first may be what *many* doctors do, and according to at least The Lancet research, it's a great way to miss most advanced liver disease until it's too late. Early disease, even early cirrhosis(!!!) has little/no symptoms. That may be why many criticize the medical profession for not doing enough about *prevention* or early intervention, and only reacting when folks are very sick.
In the US at least, the business model of medicine is skewed perversely towards a reactive, not proactive, approach. With liver disease, that approach has catastrophic consequences.
We are reactive here in UK too..sadly.
Also, have you been diagnosed with alcoholic liver disease? (Your drinking history would suggest some damage at least is likely).
If so, your reported AST/ALT values anecdotally support the point that an elevated ratio is meaningful even when enzymes are in a normal range.
But isn't it a failure on part of NHS to explain these things properly?My gp nor liver specialist haven't explained anything.
I've had minor ops done in past.. Surgeon spends say 5 mins explaining procedure, risks, % risks, questions.. None of that here.
The liver specialist and gp have seen results and diagnosis and.. Nothing.
Self care.. Nothing except don't drink.. And l hardly did pre issues (like 2 small cans beer in 4 months).
So why is it so hard for NHS to explain things?
Hi Chris,
We would suggest to speak to your own liver specialist to clarify any concerns you have.
The AST/ALT debate is ongoing on the forum at the moment and we would stress the importance of speaking with your own specialist about this and not be guided by anyone else.
Best wishes.
I never got caught up in the results and numbers. I just listened to what the doctors said such as bloods are good or if they were concerned. Then I strictly followed everything they told me to do. Don’t overthink your bloods, just listen to the medics
in reply to Roots57
That's the way to do it !
That works pre-diagnosis when blood results indicate liver disease (post-diagnosis, the ratio is irrelevant). But we know from the Lancet study that more than half of serious liver disease cases are missed when looking only at abnormal liver function results. Waiting for symptoms is too late.
The BLT's Sound the Alarm campaign rightly emphasizes the lack of sufficient early diagnosis efforts in liver disease. Folks here who mention the AST/ALT ratio is irrelevant and to rely on symptoms to identify liver damage instead miss the point-- by the time symptoms show up it's too late--that's advanced cirrhosis.
The AST/ALT ratio is one tool that could be used to identify some problem drinkers (one specific cause of liver disease) with likely liver damage before they get to the symptomatic stage.
Enzymes within the reference ranges alone *do not* mean there is no liver damage (again, see the Lancet article, others), and telling drinkers as much despite a problematic ratio is an invitation for most of them to keep drinking. Problem drinkers are great at finding reasons to deny they are problem drinking. I was a pro at it. Had I heard of the De Ritis ratio 5 years ago, though, I would have quit drinking then. As it happened, I had a liver function test, GP ignored the AST/ALT ratio and I was unaware of it, I kept drinking, and here I am.
The value of the ratio is for people who are *not diagnosed* with cirrhosis--as a way to warn those who are damaging their livers and may be on the path to serious liver disease before they get there.
What was your ratio 5 yrs ago?
AST:ALT at 17:12. Enzymes nice and low, everything else seemingly fine (except MCV borderline), so nothing was mentioned. At that point I had 10 years of regular drinking, so was already at risk of advanced liver damage, though I didn't think so or suspect it on account of my age then (32). Didn't think liver disease in 30s was possible. Knowing of the De Ritis ratio in acoholic liver disease would have been a wake up call. I had no symptoms, was seemingly thriving in all other aspects of life, so figured my liver was perfectly healthy and thought I was not drinking at a suicidal level.
Now I know, livers don't go from perfectly healthy to decompensating in five years. I may have even had early cirrhosis already then--in any case, almost certainly already had advanced fibrosis. At the very least, knowing of the ratio would have led to a change in my behavior. I understand I brought my fate on myself, and in hindsight my ignorance was absurdly naive, but still, knowledge of the ratio could have helped me. It can help others.
The smokescreen regarding the ratio in ALD that some here insist on putting up, and saying folks will be diagnosed based on symptoms, is just inviting more drinkers to drink themselves into an early and difficult grave. The ratio is useful information, and should be actually used early in more cases. Lives could be saved.
in reply to Str8jacket
I also feel that NICE guidelines actively prevent gps from referring patients with dodgy bloods results .Even at a stage when your enzymes are risen above the standard ranges . There is often an action indicated in brackets ( action required or not ) gps will not refer until the blood results reach a level that is dangerously high . This is even when other blood results such as calcium are out of range .
It is my feeling that the nhs are knowingly only catching the disease when it is too late.
Str8jacket in reply to
I am not familiar with the NHS, but I would never accuse my GP of acting in bad faith. He truly cares for his patients. And like many drinkers, I minimized my intake for fear of stigma, etc.
Also, a GP is no liver doc. If ~1 in 300 people have cirrhosis and fewer are symptomatic, a GP may only see a handful of such cases in his career. GPs deal with flus and earaches, not liver failure.
But, as has been suggested in articles on this topic, labs should report the AST/ALT ratio and flag it for clinicians/GPs/patients. Patients can then be informed of it in time to act.
Simple, and could save many lives.
My GP admitted to me yesterday, she doesn’t know much about liver, that’s why we have specialists.
in reply to Str8jacket
It can be in Britain a rather long process getting a gp referral . Even more so now with a waiting list of 5 million . To date I've had to pay for everything myself as is the experience of another member on this site .
The nhs are fantastic at dealing with life threatening conditions but getting a diagnosis can sometimes be laborious.
My consultant never mentioned this too me and I’ve only heard of it from this site. Too much information sometimes??
Once we're at cirrhosis, the ratio is not terribly relevant unless the cause is unknown.
Imagine if you saw a problematic ratio on a screening years before you had cirrhosis and were warned you had already likely damaged your liver with alcohol.
That is where use/awareness of the ratio can make a tremendous impact.
I looked a my blood test from 208 and 2019 when I just socially drank. The ast was higher so I don’t think it’s the best till alone to diagnose anything when everything else is on range
One Gp diagnosed me with constipation when I had ascites!!
Help! Am I the only person who is finding all this talk is going Waaaay over the head??? 🤔 I suddenly feel really unintelligent and uneducated!!!!!!!We just listen to the Drs and trust them. This includes local hospital gastro, GP, private specialist at Spires and the transplant team at Leeds. They all work together miraculously well, all agree with each other, and if there's ever a question to be asked they all respect Leeds as final say! Personally we have never felt the need to be more complicated than that. I'm sorry for those that don't feel they can have the same confidence - it must be exhausting. I think I'd have gone mad by now if I was having to get my head round all that
Best wishes..........
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