title: Subjects with sonographical hepatic steatosis should be excluded from studies to establish upper reference levels of serum transaminases.
abstract: OBJECTIVE
  Correct upper reference limits (URL) of serum liver enzyme activities are used to select individuals in whom further diagnostic procedures for suspected liver disorders are warranted and to compare the prevalence and incidence of increased serum liver enzyme levels within and among populations. We sought to establish URL in a general adult population by not only generating a disease-free population but also further excluding subjects with ultrasonographical diagnosis of hepatic steatosis.
  
  
  METHODS
  We used data from 4,242 subjects (2,154 women) aged 20-79 years recruited for the population-based Study of Health in Pomerania. A reference population was selected comprising 1,953 subjects (1,129 women). Serum alanine aminotransferase (ALT), aspartate aminotransferase (AST) and γ-glutamyltransferase (GGT) were measured photometrically.
  
  
  RESULTS
  The exclusion of 630 subjects with hepatic steatosis and 20 subjects with equivocal data on liver ultrasound from the reference population predominantly affected the URL for serum ALT and GGT levels in younger age groups. URL for serum ALT, AST and GGT levels were 1.00 μmol/L/s (60 U/L), 0.55 μmol/L/s (33 U/L) and 1.11 μmol/L/s (67 U/L), respectively, in men as well as 0.57 μmol/L/s (34 U/L), μmol/L/s (25 U/L) and μmol/L/s (39 U/L), respectively, in women.
  
  
  CONCLUSIONS
  URL for serum liver enzyme activities are higher than recommended previously. Creating a reference population for establishing URL for serum liver enzyme activities should include liver ultrasound in order to exclude subjects with subclinical hepatic steatosis.
authors.affiliation: Institute for Community Medicine, Unit Study of Health in Pomerania - Clinical Epidemiological Research, Ernst Moritz Arndt University, Greifswald, Germany. voelzke@uni-greifswald.de
authors.forename: Henry
authors.initials: H
authors.lastname: Völzke
authors.forename: Dietrich
authors.initials: D
authors.lastname: Alte
authors.forename: Till
authors.initials: T
authors.lastname: Ittermann
authors.forename: Carsten O
authors.initials: CO
authors.lastname: Schmidt
authors.forename: Rainer
authors.initials: R
authors.lastname: Rettig
authors.forename: Julia
authors.initials: J
authors.lastname: Mayerle
authors.forename: Albert B
authors.initials: AB
authors.lastname: Lowenfels
authors.forename: Markus M
authors.initials: MM
authors.lastname: Lerch
authors.forename: Matthias
authors.initials: M
authors.lastname: Nauck
mesh_terms: D000328:Adult; D000367:Age Factors; D000368:Aged; D005234:Fatty Liver / Q000000981:diagnostic imaging*; D005260:Female; D005858:Germany / Q000453:epidemiology; D006801:Humans; D008107:Liver Diseases / Q000097:blood* / Q000175:diagnosis*; D008297:Male; D008403:Mass Screening / Q000379:methods*; D008875:Middle Aged; D016017:Odds Ratio; D018579:Patient Selection; D012016:Reference Values; D000637:Transaminases / Q000097:blood* / Q000592:standards; D014463:Ultrasonography
chemical_list: D000637:Transaminases