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if repeated ALT > 80 IU/L

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Repeat LFTs after further one months with further blood tests:

First line investigations (2):

  • serology for hepatitis B and C
  • serum iron and total iron binding capacity: increased iron load suggests haemochromatosis
  • serum caeruloplasmin levels: decreased levels suggest Wilson's disease
  • serum protein electrophoresis:
    • increase polyclonal immunoglobulin suggests autoimmune hepatitis
    • decreased alpha-globulin suggests alpha-1 antitrypsin deficiency
  • liver autoimmune serology (especially if female)

Consider second line investigations (2):

  • the following investigations should be performed in a patient with asymptomatic elevation of aminotransferase levels who remains undiagnosed despite first-line investigations:
    • alpha-1 antitrypsin phenotyping: a ZZ phenotype is diagnostic of a deficiency state
    • antigliadin and antiendomysial serology: presence indicates coeliac disease
    • creatine kinase and aldolase: elevation indicates muscle disease

  • if ALT > 120 IU/L then refer
  • if ALT not back to normal
    • repeat LFTs after a further 3 months (and organise liver ultrasound)
        • if ALT > 80 IU/L then refer
        • if normal then no further action
        • if ALT raised but < 80 IU/L then repeat LFTs at 12 months to ensure that not rising


  1. Pulse (2004); 64 (3): 34-6.
  2. Pratt DS, Kaplan MM. Evaluation of abnormal liver-enzyme results in asymptomatic patients. NEJM 2000;342:1266-71.
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