肝纤维化/硬化与ALT的关系

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转自MEDHELP，要点：肝纤维化/硬化与ALT水平关系不大。即使ALT正常 （小于23），仍然会纤维化/硬化。

http://www.clinicaloptions.com/Hepatitis/Conference%20Coverage/AASLD%202008/Tracks/Approved%20HBV%20Agents/Approved%20HBV%20Agents/Pages/Page%2012.aspx

Association Between Liver Fibrosis/Cirrhosis and ALT Levels

Ira M. Jacobson, MD:
Elevated ALT levels and liver histology indicative of fibrosis are often major factors in the decision to initiate antiviral therapy for chronic HBV infection. A growing body of literature has shown that HBV-infected patients with normal ALT levels often have considerable liver fibrosis. A study by Goebel and colleagues[39] retrospectively analyzed the relationship between fibrosis and ALT levels in non-Asian patients with chronic HBV infection (Capsule Summary). The investigators examined liver histology in 252 patients with various ALT levels, including a substantial cohort with normal ALT levels, and showed that the incidence of cirrhosis on liver biopsy was similar between patients with normal vs elevated ALT levels. Among patients with ALT  2 times the upper limit of normal (n = 130). Significant inflammation, however, was less common in patients with normal ALT levels (26%) compared with those with elevated ALT levels (52% to 68%), but I think most experienced clinicians would treat all viremic patients with cirrhosis or advanced fibrosis, regardless of the level of inflammation.

One strength of this study is the use of definitions of normal ALT that are more consistent with current thinking than those provided by commercial labs. Specifically, the ULN was defined as 23 IU/L in males, which is actually even slightly lower than the 30 IU/L that is the current recommendation, and 19 IU/L in females. A limitation of the study is that although not explicitly stated in the abstract, ALT appears to have been assayed at only a single time point, whereas it would have been a more robust analysis if based on a differentiation of patients with persistently normal. Nevertheless, the results add to a growing body of literature suggesting that guidelines for treatment of hepatitis B should reconsider the significance of ALT levels in determining candidacy for treatment.