Guidelines on the management of abnormal liver blood tests

Newsome, Philip N.; Cramb, R.; Davison, Suzanne; Dillon, John; Foulerton, Mark; Godfrey, Edmund; Hall, Richard J.; Harrower, Ulrike; Hudson, Mark; Langford, Andrew; Mackie, Anne; Mitchell-Thain, Robert; Sennett, Karen; Sheron, Nick; Verne, Julia; Walmsley, Martine; Yeoman, Andrew D.

doi:10.1136/gutjnl-2017-314924

Cited by 409 publications

(437 citation statements)

References 64 publications

Supporting

Mentioning

391

Contrasting

Unclassified

Order By: Relevance

“…Persistently elevated liver tests despite successful HCV eradication should prompt a thorough evaluation regarding additional (alternative) causes of liver disease . Among the potential differential diagnoses like autoimmune disorders, alcoholism and non‐alcoholic fatty liver disease (NAFLD), the prevalence of NAFLD is particularly increasing, paralleling the increasing prevalence of obesity, type 2 diabetes and the metabolic syndrome worldwide .…”

Section: Discussionmentioning

confidence: 99%

Baseline risk factors determine lack of biochemical response after SVR in chronic hepatitis C patients treated with DAAs

Tacke

Boeker²,

Klinker

et al. 2019

Liver International

View full text Add to dashboard Cite

Background and Aims Liver function tests (alanine aminotransferase, ALT; gamma‐glutamyltransferase, GGT) not always normalize after elimination of hepatitis C virus (HCV) by direct acting antivirals (DAAs), possibly indicating concomitant non‐viral liver diseases. We analysed factors determining the biochemical response (normalized ALT/GGT) of DAA therapy in a large real‐world cohort. Method The German Hepatitis C‐Registry is a national multicenter registry study. Normal ALT was defined ≤35 U/L (female) and ≤50 U/L (male) or, according to AASLD, ≤19 U/L (female) and ≤30 U/L (male), normal GGT ≤40 U/L (female) and ≤60 U/L (male). Results At baseline, ALT was elevated in 3705/4946 (74.9%), ALT (AASLD) in 4669/4946 (94.4%) and GGT in 3018/4906 (61.5%). In this study, 97% of patients achieved SVR12. At week 12 after end of therapy, ALT was elevated in 451/4946 (9.1%), ALT according to AASLD in 1906/4946 (38.5%) and GGT in 863/4879 (17.7%). Persistently elevated ALT after DAA therapy was independently associated with high body mass index (BMI), age <70 years, liver cirrhosis, diabetes, alcohol consumption and not achieving SVR12. Using the stricter AASLD criteria, opioid substitution and male sex were additional predictors. Higher GGT at week 12 was associated with high BMI, age >70 years, liver cirrhosis, diabetes, alcohol consumption, opioid substitution and non‐SVR. Importantly, persistently elevated liver tests after treatment, particularly GGT, were associated with hepatic decompensation and mortality during 4‐years follow‐up. Conclusion Risk factors at baseline (obesity, diabetes, liver cirrhosis, alcohol consumption) are independently associated with persistently elevated liver function tests after SVR, indicating that these patients warrant further hepatological follow‐up. Clinical trial registration: German Clinical Trials Register (DRKS; ID DRKS00009717).

show abstract

Section: Discussionmentioning

confidence: 99%

Baseline risk factors determine lack of biochemical response after SVR in chronic hepatitis C patients treated with DAAs

Tacke

Boeker²,

Klinker

et al. 2019

Liver International

View full text Add to dashboard Cite

show abstract

“…Our findings also support the observation that the sequential use of NITs is superior to single tests in the diagnosis of cirrhosis, under the assumption that the diagnostic accuracy of the second-tier NIT is similar when used singly or sequentially. (1,(28)(29)(30)(31)…”

Section: Relationship To Previous Studiesmentioning

confidence: 99%

Defining the Minimum Acceptable Diagnostic Accuracy of Noninvasive Fibrosis Testing in Cirrhosis: A Decision Analytic Modeling Study

et al. 2019

View full text Add to dashboard Cite

No studies explore the clinical consequences of using noninvasive tests (NITs) compared to liver biopsy (LB) in diagnosing cirrhosis. Our aim was to combine two decision analytic models to determine the minimum diagnostic accuracy criteria for NITs to diagnose cirrhosis with equivalence to LB in terms of mortality. We further evaluated selected existing NITs used alone and sequentially. A decision tree was constructed with associated 2‐year mortality incorporating an LB or NIT strategy to diagnose cirrhosis in a hypothetical cohort of 1,000 asymptomatic patients. Cirrhosis prevalence was modeled at 5%, 20%, and 50%. Decision curve analyses were performed, expressing the net benefit of tests over a range of threshold probabilities (Pt). The NIT deriving from the two models that could diagnose cirrhosis with at least equal mortality to LB was termed “mNIT.” Existing NITs were then compared using both decision models. The combined mNIT minimum sensitivity and specificity to diagnose cirrhosis with equivalence to LB at 5%, 20% and 50% cirrhosis prevalence were; 89% and 88%, 94% and 85%, and 94% and 87%, respectively at Pt = 0.20. Sequential NITs performed better than single NITs at any prevalence. Combining both decision models, FibroTest plus vibration‐controlled transient elastography (VCTE) and VCTE alone were the only existing NITs that were better than or equal to LB at diagnosing cirrhosis at 5% prevalence. At 20% and 50% prevalence, only FibroTest high specificity cutoff plus VCTE was equivalent to or better than LB. Conclusion: Decision analytic models were used to determine the minimum acceptable diagnostic accuracy of NITs for diagnosing cirrhosis; we recommend that such models should be used as the standard in evaluating the diagnostic performance of NITs.

show abstract

“…Although there has been much discussion regarding the upper limit of ALT, low levels of ALT have not been emphasized. In fact, clinical practice guidelines regarding abnormal liver blood tests recommend further work‐up when patients have elevated ALT, but patients with low ALT were not addressed …”

Section: Introductionmentioning

confidence: 99%

“…Alanine aminotransferase (ALT) is one of the most commonly used biomarkers for screening liver diseases because elevated ALT reflects hepatocyte injury or death. 1 ALT is not only a biomarker of liver injury but is also an important enzyme in the liver, kidney, heart, brain, and skeletal muscle. ALT catalyzes the reaction from L-alanine and α-ketoglutarate to pyruvate and glutamate, respectively, and vice versa.…”

Section: Introductionmentioning

confidence: 99%

Association of low alanine aminotransferase with loss of independence or death: A 5‐year population‐based cohort study

Yamazaki

Kamitani

Matsui

et al. 2019

J of Gastro and Hepatol

View full text Add to dashboard Cite

Background and Aim Alanine aminotransferase (ALT) is an important enzyme for amino acid metabolism and gluconeogenesis, and low ALT is an indicator of vitamin B6 deficiency. However, it is unknown whether individuals with low ALT are likely to develop loss of independence (LOI) or death. We investigated the association of low ALT with LOI or death in the elderly. Methods Between 2008 and 2010, 2,484 elderly individuals (≥ 65 years old) without functional dependency from the Locomotive Syndrome and Health Outcomes in the Aizu Cohort Study were enrolled. Based on baseline ALT values, the participants were divided into the following groups: ALT < 10 (n = 73), 10–20 (n = 1,372), 20–30 (reference, n = 734), 30–40 (n = 201), and ≥ 40 (n = 104) U/L groups. LOI was defined as requiring complete support for basic activities of daily living, which is care levels 3–5 in Japanese long‐term care insurance certifications. The hazard ratios of LOI or death were estimated by Cox proportional hazard models adjusted for potential confounders. Results During the median follow‐up period of 5.75 (interquartile range 4.85–5.83) years, LOI or death occurred in 195 participants (7.85%). Compared with ALT 20–30 U/L, low ALT was associated with LOI or death (multivariable adjusted hazard ratios [95% confidence intervals]: 3.02 [1.57–5.81] and 1.55 [1.07–2.24] in ALT < 10 and 10–20 U/L groups, respectively), while high ALT was not (1.29 [0.72–2.31] and 1.49 [0.68–3.25] in ALT 30–40 and ≥ 40 U/L groups, respectively). Conclusions Clinicians should be aware of not only high ALT, indicating liver injury, but also low ALT associated with LOI or death.

show abstract

Guidelines on the management of abnormal liver blood tests

Cited by 409 publications

References 64 publications

Baseline risk factors determine lack of biochemical response after SVR in chronic hepatitis C patients treated with DAAs

Baseline risk factors determine lack of biochemical response after SVR in chronic hepatitis C patients treated with DAAs

Defining the Minimum Acceptable Diagnostic Accuracy of Noninvasive Fibrosis Testing in Cirrhosis: A Decision Analytic Modeling Study

Association of low alanine aminotransferase with loss of independence or death: A 5‐year population‐based cohort study

Contact Info

Product

Resources

About