Serum levels of the hepatobiliary enzyme gamma-glutamyltransferase or gamma-glutamyl transpeptidase (GGT) have recently been associated with hepatic involvement of patients with atherosclerotic cardiovascular disease (CVD). 1À3 In the current issue of JCEH, Loomba et al. 4 report a study showing that elevated serum GGT (>51 U/L in men and >33 U/L in women) seems to be an independent predictor of CVD, liver mortality and all-cause mortality in older adults (mean age 70 years). These observations were made in a prospective study of 2,364 individuals. The study results indicate that individuals with elevated GGT were more likely to be obese, hypertensive with higher systolic blood pressure, dyslipidemic, and diabetic. These risk factors are associated with the profile of an individual with metabolic syndrome who may have a very high likelihood of having underlying non-alcoholic fatty liver disease (NAFLD).In the last 5 year, there has been a renewed interest in serum GGT as an indicator of chronic diseases such as NAFLD, metabolic syndrome, CVD as well as other chronic heart diseases such as congestive heart failure. 5 In the upper reference range, GGT has been found to be an independent biomarker of metabolic syndrome (abnormal body mass index and levels of high-density lipoprotein (HDL) cholesterol, glucose, triglycerides, and systolic and diastolic blood pressure), with a 20% per GGT quartile trend rise. 6 As noted previously, GGT maybe a marker of an underlying subclinical liver disease, especially, NAFLD. This is supported by the association of a number of risk factors with GGT such as glucose, insulin resistance, cholesterol, HDL, low-density lipoprotein (LDL), alanine aminotransferase (ALT) and aspartate aminotransferase (AST). 7,8 These risk factors are however, not independent and are clustered and associated with each other. The risk factors are also associated with metabolic syndrome and its hepatic manifestation, NAFLD. In this case, adjustment for the presence of the above mentioned risk factors should decrease the strength of association of GGT with mortality. Interestingly, adjustment for the associated risk factors does not fully account for the association seen between GGT and mortality. 8,9 This is also shown in the study by Loomba et al. 4 All together, these data suggest that GGT, indeed, might directly relate to certain pathogenetic processes that may involve the liver as well as other organs, rather than being a simple co-correlate of other clinical variable.The key to untangling this relationship is in understanding the enzymatic function of GGT. This enzyme catalyzes the transfer of the gamma-glutamyl moiety of its major substrate-glutathione (GSH) to an acceptor that may be an amino acid, a peptide or water (forming glutamate), thus playing an important role in the homeostasis of GSH. It is located on the cell surface and by breaking down of extracellular GSH, it provides the rate limiting substrate-cysteine, for intracellular de novo synthesis of GSH. 10 The GGT mediated cleavage of GSH, ...