What are elevated AST and ALT levels? What causes abnormally high or low results? Explore the symptoms and underlying conditions behind liver enzyme imbalances.

Understanding AST and ALT Levels

Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are two of the most commonly measured liver enzymes. These enzymes are found in various cells throughout the body, with the highest concentrations in the liver. Elevated AST and ALT levels can be indicative of liver damage or dysfunction, while low levels may suggest certain underlying conditions.

Abnormally High AST and ALT Levels

When AST and ALT levels are elevated, it can be a sign of various health issues. Some of the most common causes of high liver enzymes include:

• Hepatitis: Viral infections such as hepatitis B, C, and E can cause significant inflammation and damage to the liver, leading to elevated AST and ALT.
• Alcohol Abuse: Excessive alcohol consumption can lead to alcoholic hepatitis, which results in increased liver enzyme levels.
• Fatty Liver Disease: Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) can cause a rise in AST and ALT.
• Medication Toxicity: Certain medications, including some over-the-counter drugs, can cause drug-induced liver injury, leading to elevated liver enzymes.
• Rhabdomyolysis: This condition, characterized by the breakdown of skeletal muscle, can cause AST levels to be significantly higher than ALT due to the distribution of these enzymes in the body.

Abnormally Low AST and ALT Levels

While high liver enzyme levels are more commonly associated with health issues, low AST and ALT levels can also indicate certain conditions, such as:

1. Vitamin B6 Deficiency: Vitamin B6 is necessary for the proper functioning of AST and ALT, and a deficiency can lead to decreased levels of these enzymes.
2. Celiac Disease: Individuals with celiac disease may have lower AST and ALT levels due to the malabsorption of nutrients caused by the condition.
3. Cirrhosis: In advanced stages of liver disease, such as cirrhosis, the liver may lose the ability to produce AST and ALT, leading to low levels.
4. Hypothyroidism: Thyroid dysfunction, specifically hypothyroidism, can result in decreased AST and ALT levels.

Interpreting AST and ALT Results

When interpreting AST and ALT results, it’s important to consider the specific levels, as well as the ratio between the two enzymes. A high AST:ALT ratio (greater than 2) may be indicative of conditions like alcoholic liver disease or rhabdomyolysis, while a low ratio (less than 1) may suggest non-alcoholic fatty liver disease or viral hepatitis.

Symptoms and Underlying Conditions

The symptoms associated with abnormal AST and ALT levels can vary depending on the underlying cause. Common symptoms may include fatigue, nausea, abdominal pain, and jaundice. It’s important to seek medical attention if you experience any of these symptoms or have concerns about your liver enzyme levels.

Diagnosing the Cause

Determining the underlying cause of abnormal AST and ALT levels typically involves a comprehensive medical evaluation, including a review of your medical history, physical examination, and laboratory tests. Your healthcare provider may also order additional tests, such as imaging studies or liver biopsy, to confirm the diagnosis and guide appropriate treatment.

Managing Abnormal Liver Enzyme Levels

The treatment for abnormal AST and ALT levels will depend on the underlying cause. In some cases, addressing the underlying condition, such as treating a viral infection or making lifestyle changes to manage fatty liver disease, can help normalize liver enzyme levels. In other cases, medication or other medical interventions may be necessary.

It’s important to work closely with your healthcare provider to develop a personalized treatment plan and monitor your progress. Regular check-ups and follow-up tests can help ensure that your liver enzymes remain within the normal range and that any underlying health issues are properly managed.

A Case of Psychosis and Elevated AST and ALT

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August 9, 2020

Tom Couri

Case

A 22-year-old male with a past medical history of anxiety and depression presents with acute psychosis after ingesting 3.5 grams of marijuana. He takes vortioxetine at home. On presentation, he was found agitated, throwing himself against walls.  AST and ALT were 187 U/L and 44 U/L on admission. Five days later, AST and ALT increased to 1,402 U/L and 402 U/L. All other liver chemistry tests, hemoglobin, white blood cell count, and INR are normal.

What is the most likely cause of his abnormal liver chemistry tests?

Drug-induced liver injury from vortioxetine
Wilson Disease
Rhabdomyolysis
Drug-induced livery injury from marijuana
Alcoholic hepatitis

Correct Answer:

Rhabdomyolysis

While the other options are possible, rhabdomyolysis is the most likely answer in the differential given the pattern of liver enzyme elevation and clinical history. The self-harm experienced by the patient caused skeletal muscle necrosis, which is reflected in the liver chemistries: an aspartate aminotransferase: alanine aminotransferase (AST:ALT) ratio >3. This diagnosis was confirmed by an elevated creatine kinase (CK) level. Keep reading to learn how rhabdomyolysis causes certain liver chemistry abnormalities and how to differentiate this disease from the others listed.

Diagnosis of rhabdomyolysis and liver-related sequelae

• Experts diagnose rhabdomyolysis in patients who have experienced a neuromuscular insult with a sudden increase in CK level, classically greater than five times the upper limit of normal and often greater than 5,000 U/L.
• A muscle biopsy, MRI, or EMG is not needed for diagnosis.

Back to the case

In this case, creatinine kinase was elevated on admission to 83,000 U/L indicating skeletal muscle injury.

• AST and ALT abnormalities are common in rhabdomyolysis, occurring in 93. 1% and 75.0% cases respectively.  
• Both AST and ALT are found in different cells throughout the body, including skeletal muscle (most pertinent to our case), red blood cells, and brain cells. AST, however, is found in greater concentrations in skeletal myocytes when compared to ALT. As a result, a ratio of AST:ALT >3 is generally observed in cases of rhabdomyolysis.

Back to the case

In order to definitively diagnose or exclude a case of drug-induced liver injury from either vortioxetine or marijuana, a thorough workup for intrinsic causes of liver disease and a liver biopsy would be needed.

• This patient had an extensive serologic workup for acute and chronic causes of liver disease; hepatitis A, B, C, and E, serum Epstein-Barr virus (EBV), cytomegalovirus (CMV), herpes simplex virus (HSV), anti-smooth muscle antibody, anti-nuclear antibody, anti-mitochondrial antibody, acetaminophen level, ceruloplasmin, alpha-1 antitrypsin phenotype, and ferritin levels were normal.
• An abdominal ultrasound with doppler was unremarkable.
• A liver biopsy was not performed due to diagnosis of rhabdomyolysis (given elevated CK level) and improvement with rhabdomyolysis treatment (see below).
• While Wilson Disease should be considered due to patient’s young age and history of psychiatric illness, this is less likely given a normal ceruloplasmin, hemoglobin and bilirubin level, and the lack of a low alkaline phosphatase in comparison to an elevated bilirubin.
• Given an AST:ALT ratio >2, alcoholic hepatitis should also be considered in the differential. However, in alcoholic hepatitis, an elevated bilirubin and leukocytosis is typically present, which was not noted in this case. Furthermore, liver enzyme elevations in the thousands, as seen in this case, are not seen in alcoholic hepatitis (Don’t forget the most common cause of transaminases in the thousands for hospitalized patients).
• COVID-19 should also be a consideration as it can cause AST>ALT liver enzyme elevations.

Given the significant elevation in CK, rhabdomyolysis is the most likely cause of abnormal liver enzymes.

Natural history of liver-related sequelae

Treatment of rhabdomyolysis entails aggressive fluid resuscitation. The AST and ALT should improve as the CK improves and the muscle injury resolves. It is important to remember that AST has a shorter half-life (~17 hours) than ALT (~47 hours)—because of this difference, the AST levels improve faster than the ALT levels (Figure 1), and the AST:ALT ratio will change as the patient’s disease course improves.

Figure 1: Changes in AST and ALT levels after their peak in a case series of muscle injury patients.

ALT: alanine aminotransferase; AST: aspartate aminotransferase. Taken from: Nathwani, R, et al. Serum Alanine Aminotransferase in Skeletal Muscle Diseases.Hepatology 2005. 41(2): 380-382.

One study showed that AST values, but not ALT values, decreased correspondingly with CK values in the first six days of hospitalization for rhabdomyolysis (Figure 2).

Figure 2: Decreases in AST mirror decreases in CK as rhabdomyolysis is treated.

Triangles are ALT values, squares are AST values, and diamonds are CK values. CK: creatine kinase; ALT: alanine aminotransferase; AST: aspartate aminotransferase. Taken from: Weibrecht, K, et al. Liver Aminotransferases are Elevated with Rhabdomyolysis in the Absence of Significant Liver Injury. J Med Toxicol 2010. 6:294-300.

• Another important point to keep in mind: The transaminase increase is not a result of liver injury, but rather skeletal muscle injury.
• As the patient continues to improve, serial liver chemistry tests should be performed to ensure improvement in the AST and ALT values. Liver chemistry tests should be checked after resolution of the rhabdomyolysis to document normalization of the AST and ALT values.

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alt and ast – Translation into Russian – examples English

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ALT and AST

ALT and AST

ALT and AST

During the first months of treatment patients often record increased ALT and AST .

In the first months of treatment, an increase in ALT and AST is quite often recorded in patients.

How to reduce ALT and AST depends on the diagnosis and prescription of the doctor.

How to reduce ALT and AST depends on the diagnosis and doctor’s prescription.

Increased ALT and AST as a result of diseases of other organs (autoimmune thyroiditis, mononucleosis).

An increase in ALT and AST as a result of a disease of other organs (autoimmune thyroiditis, mononucleosis).

If the ALT and AST values ​​exceed the upper limit of the norm by more than 5 times, nevirapine should be immediately withdrawn.

If ALT and AST values ​​are more than 5 times the upper limit of normal, nevirapine should be discontinued immediately.

Even if the patient has ALT and AST values ​​within the normal range, antiviral agents are still prescribed.

Even if the patient’s ALT and AST are within the normal range, antiviral agents are still prescribed.

In one patient, elevated ALT and AST were considered likely related to treatment.

In one patient, elevated ALT and AST were considered likely treatment related.

In all patients before treatment was expressed by cytolytic syndrome with increased ALT and AST in 1. 5 – 3.2 times.

All patients before the start of treatment had a pronounced cytolytic syndrome with an increase in ALT and AST by 1.5-3.2 times.

Depending on the indications, stress tests and clinical analyzes may be performed, especially on the concentration of ALT and AST .

Depending on the indications, stress tests and clinical analyzes can be performed, especially for the concentration of ALT and AST .

What does the increase in ALT and AST above the norm

What does the increase in ALT and AST above the norm mean?

What to do if ALT and AST are elevated

What to do if ALT and AST are elevated?

Before prescribing statins, along with a lipid profile, the doctor will most likely prescribe an analysis for transaminases ( ALT and AST ) – biochemical indicators of the liver.

Before prescribing statins, along with a lipid profile, the doctor is likely to prescribe a transaminase test ( ALT and AST ) – biochemical indicators of the state of the liver.

In adults, the content of ALT and AST in different organs is not the same, therefore an increase in one of these enzymes may indicate a disease of a certain organ.

The content of ALT and AST in different organs is not the same, therefore, an increase in one of these enzymes may indicate a disease in a particular organ.

Most often, the spectrum of enzymes in a biochemical test is limited to the analysis of “liver function tests,” AlT and AST , and amylase.

Most often, the spectrum of enzymes in a biochemical test is limited to the analysis of “liver samples”, ALT and AST , and amylase.

The workers taking the milk thistle extract showed significant improvement in liver function tests ( ALT and AST ) and platelet counts vs. the placebo group.

Workers taking milk thistle extract showed significant improvement in liver function tests (ALT and AST ) and platelet levels compared to the placebo group.

The level of ALT and AST in the main group reduced from 146.3 to 37.1 and from 107.7 to 14.2, respectively.

The level of ALT and AST in the main group decreased from 146.3 to 37.1 and from 107.7 to 14.2, respectively.

Increases in liver transaminases ( ALT and AST ) were seen in some patients; these increases were generally mild and reversible, with no hepatic injuries or any observed impact on liver function.

Liver enzyme levels ( ALT and AST ) increased in some patients; this increase was usually mild and reversible, not accompanied by signs of liver damage or any marked effect on liver function.

Presents with palpable purpura, and alt and ast are through the roof.

Presented with palpable purpura, ALT and AST above roof.

Presents with palpable purpura, and alt and ast are through the roof.

Do you think stage 4 glioblastoma in an 8-year-old girl can disappear in 3 weeks?

Increased ALT and AST more than in 10 times higher than normal is a reliable test of acute hepatitis.

A ALT and AST increase more than 10 times normal is a reliable test for acute hepatitis.

Acetominiphen toxicity can result in ALT and AST levels greater than 50x normal.

Acetaminophen poisoning can cause ALT and AST levels to rise up to 50 times normal.

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ALT up to 50% discount

Test description

Index

ALT is a test that is used to evaluate liver function. An increase in ALT in the blood in a certain proportion with another enzyme, AST may also indicate a previous heart attack.

Appointments

As a rule, it is necessary after a long-term use of medications, interaction with toxic substances (including alcohol), in the diagnosis of hepatitis, suspected pancreatitis.

Specialist

It is prescribed both in a complex of biochemical analyzes, and separately, by a therapist or hepatologist.

Important

The results of the analysis are very significantly affected by food intake, so it is important to strictly abstain for 12 hours before blood sampling.

Test method – UV kinetic test

Test material
— Blood serum

Deadline

The analysis will be ready in
within 2 days, excluding the day of collection.
The term can be extended by 1 day if necessary.
You will receive results by email. email as soon as it’s ready.

Deadline: within 2 days, excluding the day of sampling, excluding Saturday and Sunday (except for the day of taking the biomaterial)

How to prepare

In advance

Do not take a blood test immediately after X-ray, fluorography, ultrasound, physiotherapy.

The day before

24 hours before blood sampling:

• Limit fatty and fried foods, do not take alcohol.

• Avoid strenuous exercise.

From 8 to 14 hours before donating blood, do not eat, drink only clean still water.

On the day of donation

Before blood sampling

• Do not smoke for 60 minutes,
• 15-30 minutes to be in a calm state.

Result

Analysis result example.pdf

Explanation

Interpretation of test results is for informational purposes only and does not constitute a diagnosis or
replaces medical advice. Reference values ​​may differ from those indicated in
depending on the equipment used, the actual values ​​will be indicated on the form
results.

Unit: u/l

Reference values:

Increase:

• Necrosis of liver cells of any etiology (viral hepatitis, toxic liver damage).
• Cirrhosis of the liver.
• Cholestatic and obstructive jaundice.
• Myocarditis.
• Heart failure.
• Myocardial infarction.
• Myositis.
• Major trauma and necrosis of skeletal muscle.
• Pancreatitis.
• Burn disease.
• Alcoholism.
• Liver cancer (primary and metastatic).

Decrease:

• Has no diagnostic value.

Quality Assurance

Examination performed by Biochemistry Analyzer AU 5800 from Beckman Coulter, USA

Modular technology that provides simultaneous work with a large number of samples, high speed of their processing, dosing accuracy for each study, which minimizes the total testing time

ALT

Learn more about biochemical blood tests:

Do’s and don’ts before a blood test?

How to decipher the general and biochemical blood tests?

Biochemical blood tests – meaning and importance

ALT is an enzyme from the group of aminotransferases, which is responsible for amino acid metabolism and is produced intracellularly. Normally, the content of ALT in the blood is negligible, and the highest level of the enzyme is observed in the liver cells. Therefore, with an increase in the concentration of ALT in the blood, the first suspicion falls on asymptomatic lesions of this particular organ. As a rule, this analysis is necessary after a long-term use of medications, interaction with toxic substances (including alcohol), in the diagnosis of hepatitis, and suspicion of pancreatitis.

An increase in ALT in the blood in a certain proportion with another enzyme, AST (aspartate aminotransferase), may also indicate a previous heart attack. The results of the analysis are very significantly affected by food intake, so it is important to strictly abstain for 12 hours before blood sampling.

ALT (alanine aminotransferase, ALAT) is an intracellular enzyme from the group of transferases, a subgroup of transaminases, which catalyzes the conversion of a-keto acids into amino acids by transferring amino groups. Normally, only a small part of this enzyme disappears into the blood. The enzyme is present mainly in the cytoplasm of hepatocytes, but it is also found in skeletal muscle and myocardial cells. The biochemical activity of ALT in the liver is almost 10 times higher than in the myocardium and skeletal muscles, therefore, an increase in the level of ALT in the blood is mainly considered as an indicator of damage to the liver parenchyma. When liver cells are damaged, the integrity of their membrane is violated and ALT enters the bloodstream. ALT has a greater diagnostic sensitivity in diseases of the hepatobiliary system than AST.

If a biochemical blood test ALT (ALAT) showed an increase in ALT activity by 50 times or more, then this can mainly be due to acute violation of hepatic perfusion, acute necrosis of liver cells caused by exotoxins, including paracetamol and carbon tetrachloride, viral hepatitis, infectious mononucleosis. An increase in the concentration of ALT in the blood is diagnostically significant, since its level increases even before the appearance of other clinical symptoms of liver diseases (jaundice, etc. ). With viral hepatitis, an increase in enzyme activity occurs at a very early time – in the prodromal period (it is noted in 50% of patients – in 5 days, in 90% – 2 days before the clinical manifestation of the disease).

High values ​​of ALT and AST in the results of a biochemical blood test are also observed in toxic hepatitis, especially in severe cases. A moderate increase in transaminases is observed with alcoholic liver damage. Depending on the stage of the cirrhotic process, the levels of ALT and AST can be either at the upper limit of normal, or at a 4-5-fold increase from the upper limit (the level of AST is higher than ALT). In patients with primary or metastatic liver carcinomas, an increase in transaminase activity by 5-10 times is observed, however, there are cases when their level remains within the normal range, mainly in the early stages of malignant infiltration of the organ. The level in the blood test ALT (ALAT), exceeding more than 15 times the upper limit of normal, is always an indicator of acute hepatocellular necrosis of toxic, viral or circulatory origin.