Intended for healthcare professionals

Rapid response to:

Practice Rational Testing

Investigating mildly abnormal serum aminotransferase values

BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c4039 (Published 30 July 2010) Cite this as: BMJ 2010;341:c4039

Rapid Response:

Endocrine causes of elevated transaminases

Although not mentioned by the authors(1), attention needs to be
drawn, as in a recent review, to the association of Addison's disease and
elevation of alanine aminotransferase(ALT) and aspartate
aminotransferase(AST), respectively(2).

A review of 17 published cases of
this association documented that, in eleven of those instances, fatigue
was also a feature, and that in the remaining six without this symptom,
pointers to endocrine disease were found in four, namely, Addisonian
crisis in two, and hyperpigmentation and dysmenorrhoea, respectively, in
two others. Only two of the seventeen patients were asymptomatic at the
time of presentation with abnormal transaminases. Although, at the time of
writing (in 2009), the underlying pathophysiology of the liver dysfunction
remained speculative(2), the underlying message for clinicians is that
symptoms and signs of Addison's disease should also be actively sought in
patients who present with unexplained elevation of ALT and AST.. Secondary
hypoadrenalism, too, may be associated with raised ALT and AST, although,
in this context, hepatic dysfunction may have been attributable to hepatic
congestion consequent of hypoadrenalism-related pericardial effusion with
tamponade(3).

A recent review also drew attention to the fact that
elevation in ALT and AST can occur in as many as 27% and 37%,
respectively, of patients with hyperthyroidism, and that jaundice and
severe cholestasis can occur in some instances(4). In the context of
hyperthyroidism hepatic dysfunction is thouht to be attributable to
mitochondrial dysfunction(4). At the other extreme is the association of
hypothyroidism and hepatic dysfunction, exemplified by the fact that "[a]
prevalence of hypothyroidism in patients with NASH(nonalcoholic
steatohepatitis) [is] double that seen in controls(odds ratio 2.3, 95% CI
1.2-4.2)". Citing this statistic, the authors suggested that
hypothyroidism, via hyperlipidaemia and obesity, might trigger the
NAFLD(non-alcoholic fatty liver disease)-mediated chain of event that lead
to NASH(4)

References

(1) Cobbold JFL., Anstee QM., Thomas HC
Investigating mildly abnormal serum aminotransferase values
BMJ 2010;341:297-9

(2) Kalambokis GK., Milionis HJ
Addison's disease and hypertransaminasemia
Expert Rev Endocrinol Metab 2009;4:251-261

(3) Desai NR., Cheng S., Nohria A., Halperin F., Guigliano RP
When past is prologue
N Engl J Med 2009;360:1016-22

(4) Loria P., Carulli L., Bertolotti M., Lonardo A
Endocrine and liver interaction: the role of endocrine pathways in NAS
Nat Rev Gastroenetrol Hepatol 2009;6:236-47

Competing interests:
None declared

Competing interests: No competing interests

09 August 2010
oscar,m jolobe
retired geriatrician
manchester medical society