Liver function tests and metabolic-associated fatty liver disease: Changes in upper normal limits, does it really matter?
Liver function tests and metabolic-associated fatty liver disease: Changes in upper normal limits, does it really matter?
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DOI：
10.4254/wjh.v13.i12.2104
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发表时间：
2021-12-27
影响因子：
2.4
通讯作者：
Manousou P
中科院分区：
文献类型：
--
作者：
Forlano R;Mullish BH;Dhar A;Goldin RD;Thursz M;Manousou P
代谢相关性脂肪肝（MAFLD）是肝功能检查异常（LFT）的最常见原因。目前LFT的正常上限（UNL）来自“健康”人群，其中可能怀疑未诊断的MAFLD和病毒性肝炎。 评估MAFLD中丙氨酸氨基转移酶（ALT）UNL变化的潜在意义。我们回顾性评估了2010年至2017年诊断为MAFLD的连续首次转诊。ALT的常规UNL为男性45 IU/L和女性34 IU/L，而ALT的低UNL为男性30 IU/L和女性19 IU/L。天冬氨酸转氨酶（AST）的UNL为40 IU/L。共入组436例患者;其中288例接受了肝活检。设定较低的UNL降低了ALT正常但仍有显著疾病的患者的百分比;特别是，ALT正常的晚期纤维化（F ≥ F3）或明确的“代谢相关脂肪性肝炎（MASH）”（NAS ≥ 5）患者分别从10%降至1%和从28%降至4%。然而，ALT升高且无晚期纤维化或“明确MASH”证据的患者比例从39%增加到47%，从3%增加到19%。总体而言，LFT在区分“明确MASH”与单纯脂肪变性方面表现不佳（ALT和AST的曲线下受试者工作特征面积分别为0.59和0.55）。肝功能检查可能低估和高估MASH相关的肝脏疾病。降低UNL可能没有好处，并意味着医疗负担的增加。MAFLD的风险分层应依赖于风险因素的组合，而不仅仅是LFT。
Metabolic-associated fatty liver disease (MAFLD) is the commonest cause of abnormal liver function tests (LFTs). Current upper normal of limit (UNL) of LFTs was derived from a “healthy” population, where undiagnosed MAFLD and viral hepatitis might be suspected. To evaluated potential implications of changes in UNL of alanine aminotransferase (ALT) in MAFLD. We retrospectively assessed consecutive first referrals with a diagnosis of MAFLD from 2010 to 2017. The conventional UNL of ALT was 45 IU/L for men and 34 IU/L for women, while a low UNL of ALT was 30 IU/L for men and 19 IU/L for women. The UNL of aspartate aminotransferase (AST) was 40 IU/L. Total 436 patients were enrolled; of these, 288 underwent liver biopsy. Setting a lower UNL reduced the percentage of those with significant disease despite normal ALT; specifically, patients with advanced fibrosis (F ≥ F3) or definite “metabolic-associated steato-hepatitis (MASH)” (NAS ≥ 5) within normal ALT decreased from 10% to 1% and from 28% to 4% respectively. However, the proportion of those with elevated ALT and no evidence of advanced fibrosis or “definite MASH” increased from 39% to 47% and from 3% to 19%. Overall, LFTs performed poorly in distinguishing “definite MASH” from simple steatosis (receiver operating characteristic areas under the curves 0.59 for ALT and 0.55 for AST). Liver function tests might both under- and overestimate MASH-related liver disease. Reducing the UNL might not be beneficial and imply an increase in healthcare burden. Risk stratification in MAFLD should rely on a combination of risk factors, not on LFTs alone.
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