Increased ALT/AST: Work-up & Management

Identify potential cause of increased liver enzymes, using the following steps:

* In chronic Hepatitis B, we recommend the use of APRI or transient elastography. An APRI score >0.5 or transient elastography value >7 kPa identify most adults with significant liver fibrosis. An APRI >0.5 is recommended as a key criterion for giving priority to initiating antiviral therapy in resource-limited settings.

See Liver Cirrhosis: Classification and Surveillance 
See Liver Cirrhosis: Management
See Dose Adjustment of ARVs for Impaired Hepatic Function

1. > 20 g in women, > 30 g in men
2. Reflex anti-Hepatitis delta (HDV) testing if a patient is HBsAg positive
3. Metabolic dysfunction-associated steatohepatitis, see MASLD
4. APRI, AST to Platelet Ratio Index = (AST in IU/L) / (AST Upper Limit of Normal in IU/L) / (Platelets in 10⁹/L)
5. FIB-4 = Age [years] x AST [U/L])/platelet [10⁹/L] x ALT^1/2 [U/L]). For MASLD aetiology FIB-4 cut offs are as follows: < 1.30 (low risk), > 2.67 high risk.
   FIB-4 cut off < 2.0 (instead of < 1.30) should be considered in persons aged > 65 years