新的ACG指南对肝脏化疗降低正常的ALT水平

StephenW

New ACG guideline on liver chemistries lowers normal ALT level

Kwo PY. Am J Gastroenterol. 2016;doi:10.1038/ajg.2016.517.
December 21, 2016

The American College of Gastroenterology has published the first new guideline in over 10 years on the evaluation of abnormal liver chemistries, which provides a framework for physicians to approach this common problem, and notably sets new lower thresholds defining normal serum alanine aminotransferase levels.

“What is unique about the ACG guideline is that for the first time in a liver test guideline, a normal healthy [alanine aminotransferase (ALT)] level is defined for women and men (19-25 IU/L [for women], 29-33 IU/L [for men]), and levels above this should be assessed by physicians,” Paul Y. Kwo, MD, FACG, FAASLD, of the division of gastroenterology/hepatology in the department of medicine at Stanford University School of Medicine, Palo Alto, Calif., told Healio.com/Hepatology. “This decision was based on the emerging data over the past decade demonstrating that ALT levels above our defined thresholds are associated with higher liver related mortality rates across a broad range of populations world-wide including populations from the U.S., Europe, and Asia that is driven in part by the obesity epidemic.”

Paul Y. Kwo
Paul Y. Kwo

Kwo and his co-authors — Stanley M. Cohen, MD, FACG, FAASLD, of the Digestive Health Institute at University Hospitals Cleveland Medical Center, and the division of gastroenterology and liver disease, department of medicine at Case Western Reserve University School of Medicine in Cleveland, and Joseph K. Lim, MD, FACG, FAASLD, of the Yale Viral Hepatitis Program at Yale University School of Medicine in New Haven, Conn. — acknowledged that others have argued against lowering ALT thresholds as it would lead to higher health care costs, unnecessary evaluations, mental anguish and anxiety, and a reduced blood donation pool. However, the guideline authors maintained that the emerging data mentioned above warrant educating clinicians about “the adverse long-term outcomes of these historically non-elevated levels,” and standardizing ALT levels across populations.

“We recognize that it will take time for clinicians to recognize the newer lower limits of ALT levels that should now be considered normal,” Kwo said.

The guideline also provides management algorithms to help clinicians evaluate elevated ALT levels.

“We have devised algorithms that allow a graded approach to those with elevated aminotransferase elevations by categorizing these elevations as minimal, mild, moderate and severe, as well as giving specific guidelines as to when immediate evaluation is required and when a more limited evaluation can be performed with subsequent evaluation if liver chemistries fail to normalize,” Kwo said.

Moreover, the guideline authors provide additional algorithms for evaluating abnormal alkaline phosphate levels and bilirubin levels, “to help clinicians efficiently evaluate these abnormalities including suggested serologic and radiologic evaluations as well as when liver biopsy should be considered,” Kwo added.

This practice guideline is intended to be flexible and adjusted for individual patients, and the quality of evidence used to develop it was classified using a modified grading of recommendation assessment, development and evaluation workup. – by Adam Leitenberger

Disclosures: The researchers report no relevant financial disclosures

StephenW

新的ACG指南对肝脏化疗降低正常的ALT水平

Kwo PY。 Am J Gastroenterol。 2016; doi：10.1038 / ajg.2016.517。
2016年12月21日

美国胃肠病学会在超过10年中发表了关于异常肝化学的评价的第一个新指南，其为医生解决这个常见问题提供了框架，并且特别地设定了限定正常血清丙氨酸氨基转移酶水平的新的更低阈值。

“ACG指南的独特之处在于，在肝脏检查指南中，首次为女性和男性确定了正常的健康[丙氨酸氨基转移酶（ALT）]水平（19-25 IU / L [女性]，29 -33 IU / L [对于男性]），并且高于该水平的水平应由医生评估，“Stanford大学学院的医学部胃肠病学/肝病学分区的Paul YKwo，MD，FACG，FAASLD医学，加利福尼亚州帕洛阿尔托，告诉Healio.com/Hepatology。 “这一决定是基于过去十年中新出现的数据，表明ALT水平高于我们定义的阈值与世界范围广泛的人群包括来自美国，欧洲和亚洲的人群的肝脏相关死亡率升高有关部分是由于肥胖的流行。

保罗·Kwo
保罗·Kwo

Kwo和他的合作者 - Stanley M. Cohen，MD，FACG，FAASLD，大学医院Cleveland医学中心的消化系统健康研究所，以及Case Western Reserve大学医学院的胃肠病学和肝病部门在耶鲁大学医学院耶鲁大学医学院的耶鲁病毒性肝炎计划的约克K.林，MD，FACG，FAASLD - 承认其他人已经反对降低ALT阈值，因为它会导致更高的健康护理费用，不必要的评估，精神痛苦和焦虑，以及减少献血池。然而，指南作者认为，上述新出现的数据需要教育临床医生“这些历史上非升高水平的不良长期结果”，并标准化人群中的ALT水平。

“我们认识到，临床医生需要时间来认识到ALT水平的更低的下限，现在应该被认为是正常的，”Kwo说。

该指南还提供管理算法，以帮助临床医生评估升高的ALT水平。

“我们设计了算法，通过将这些升高分类为最小，轻度，中度和重度，以及对何时需要立即评估以及何时进行更有限的评估，允许对具有升高的氨基转移酶升高的那些升级的分级方法如果肝脏化学物质不能正常化，则进行随后的评价，“Kwo说。

此外，指南作者提供了额外的算法，用于评估异常碱性磷酸盐水平和胆红素水平，“以帮助临床医生有效地评估这些异常，包括建议的血清学和放射学评价，以及当肝活检时应考虑。

该实践指南旨在对各个患者进行灵活和调整，并且使用推荐评估，开发和评估工作的修改分级对用于开发的证据的质量进行分类。 - 由亚当Leitenberger

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