Division of HepatologyDepartment of Internal MedicineCerrahpasa Medical SchoolIstanbul UniversityIstanbul, Turkey
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To the Editor:As mentioned in the article by McCullough, 1 the most commonly reported biochemical liver function test abnormalities in patients with nonalcoholic steatohepatitis (NASH) is mildly to moderately elevated serum levels of aminotransferase [alanine aminotransferase (ALT) and/or aspartate aminotransferase (AST)]. Persistent aminotransferase elevations are also required for further examination. Although high serum levels of aminotransferase are not a criterion for NASH diagnosis, they are frequently used for assessing therapy response. 2–5 There is not enough information about aminotransferase levels changing in the nature of NASH, so it is not easy to assess the results of therapy. For these reasons, we aimed to evaluate aminotransferase level variabilities in patients with NASH [this work has been accepted for presentation at the Clinical Research Single Topic Conference: Nonalcoholic Steatohepatitis (NASH), Atlanta, Georgia, September 20–22, 2002].In this trial, we studied 31 patients with NASH. In all patients the diagnosis of NASH was performed by liver biopsy, and those patients who had taken alcohol (>20 g/d), hepatotoxic drugs, blood transfusion, or those with a history of viral or autoimmune hepatitis were not included in the study. Serum aminotransferase levels were measured for 4 months. At the beginning of the trial, ALT was higher than AST in 27 cases. ALT was abnormal in 31 cases: for ALT, less than 1.5 times the upper limit of normal (ULN) in 1 case, between 1.5 to 3 times the ULN in 23 cases, and more than 3 times the ULN in 7 cases. However, AST was abnormal in 29 cases: for AST, less than 1.5 times the ULN in 13 cases, between 1.5 to 3 times the ULN in 14 cases, and more than 3 times the ULN in 2 cases. Table 1 summarizes the results.Eleven of 31 patients with NASH had at least one normal ALT measurement in controls. At the end of the trail, ALT was normal in 8 of 11 cases, but 4 cases lost weight (8–19% kg). At the beginning of the trial, ALT levels of those 8 cases were as follows: more than 3 times the ULN in 2 cases and between 1.5 to 2 times the ULN in 6 cases. The body mass index of three cases was increased, but we could not see any important change on their serum levels of aminotransferase. The ALT levels of 10 of 31 cases were decreased but still more than ULN, and the ALT levels of another six cases were increased (>25%); 18 of 31 patients with NASH had at least one normal AST measurement in controls. At the end of the trail, AST was normal in 14 of 18 cases: for those 14, less than 1.5 times the ULN in 8 cases and between 1.5 to 3 the ULN in 6 cases at the beginning of the trial. Six of them lost weight and 3 of 6 cases had also normal ALT levels. The rest of the cases did not reach normal levels, and AST levels were decreased in six cases. AST levels of two cases that gained weight were not increased. AST level of one case gained 20.6% kg was decreased. The AST levels of six cases were increased (>25%). In conclusion, our observations suggest that serum aminotransferase levels fluctuate in NASH and do not reliably guide to assess therapy response.Süleyman H. Ipekci, M.D.Metin Basaranoglu, M.D.Abdullah Sonsuz, M.D.