title: Is serum alanine transaminase level a reliable marker of histological disease in chronic hepatitis C infection?
abstract: BACKGROUND
  Approximately 20-30% of patients chronically infected with hepatitis C virus (HCV) have persistently normal alanine transaminase (PNALT) levels. These patients are described to have a mild degree of histological liver damage. We aimed to assess the histological liver changes in HCV patients with PNALT.
  
  
  METHODS
  Sixty-five patients with HCV and PNALT (group A) underwent a liver biopsy. PNALT was defined as three or more determinations identified to be within the normal range over 6 months or longer. The demographical features and histological changes were compared with 66 consecutive patients with chronic HCV infection and elevated ALT (group B). All patients had a detectable HCV RNA. Histological disease was scored according to the METAVIR system.
  
  
  RESULTS
  Females were more likely to have normal ALT levels (65%). The mean ALT level in Group A and B was 30 and 105 IU/L respectively. No patient in either group had normal histology. The mean necro-inflammatory scores in groups A and B (2.0+/-0.68 vs 2.09+/-0.67) and the mean fibrosis scores (2.11+/-0.87 vs 2.24+/-1.04) were not significantly different. Bridging fibrosis in groups A and B was seen in 24.6 and 37.9% patients, respectively, while cirrhosis was seen in 6.2 and 7.6% patients respectively. Hepatic steatosis in groups A and B (0.94+/-0.86 vs 1.0+/-1.02 respectively) was also not significantly different and did not show any association with the fibrosis scores across the two groups. In group A, the necro-inflammatory and fibrosis scores of patients with and without steatosis were not statistically significant. Age was the only predictor of normal ALT levels. However, increasing age did not show a significant increase in histological activity in either group beyond a certain age.
  
  
  CONCLUSIONS
  This study demonstrates that ALT is a poor surrogate marker for inflammation and fibrosis in HCV patients. Given the presence of significant necro-inflammation in PNALT patients, the risk/benefit ratio justifies treatment without the need for a liver biopsy.
authors.affiliation: Department of Medicine, Division of Gastroenterology and Hepatology, Riyadh Military Hospital, Riyadh, Saudi Arabia. fsanai@rmh.med.sa
authors.forename: Faisal M
authors.initials: FM
authors.lastname: Sanai
authors.forename: Ali
authors.initials: A
authors.lastname: Benmousa
authors.forename: Hussa
authors.initials: H
authors.lastname: Al-Hussaini
authors.forename: Suhail
authors.initials: S
authors.lastname: Ashraf
authors.forename: Osama
authors.initials: O
authors.lastname: Alhafi
authors.forename: Ayman A
authors.initials: AA
authors.lastname: Abdo
authors.forename: Hatem F
authors.initials: HF
authors.lastname: Alameri
authors.forename: Hisham O
authors.initials: HO
authors.lastname: Akbar
authors.forename: Khalid I
authors.initials: KI
authors.lastname: Bzeizi
mesh_terms: D000410:Alanine Transaminase / Q000097:blood*; D015415:Biomarkers / Q000097:blood*; D001706:Biopsy; D005234:Fatty Liver / Q000097:blood / Q000473:pathology; D005260:Female; D005355:Fibrosis / Q000097:blood / Q000473:pathology; D016174:Hepacivirus / Q000235:genetics; D019698:Hepatitis C, Chronic / Q000175:diagnosis* / Q000201:enzymology; D006801:Humans; D008099:Liver / Q000473:pathology; D008103:Liver Cirrhosis / Q000097:blood / Q000473:pathology; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D012367:RNA, Viral / Q000097:blood; D012737:Sex Factors
chemical_list: D015415:Biomarkers; D012367:RNA, Viral; D000410:Alanine Transaminase