Mohamed A. Metwally, Claudia O. Zein, Nizar N. Zein, Rochester, MN

It has been suggested that chronic HCV patients with persistently normal ALT values tend to have minimal histologic activity or fibrosis. Treatment of these patients is therefore still controversial.

The aims of this study were to:

Study the prevalence of normal ALT at the time of first evaluation in patients with chronic HCV.

1.   Assess the relationship between hepatic fibrosis, inflammatory activity, and normal ALT in HCV patients.

198 previously untreated consecutive patients with chronic HCV were included. All patients had serological, virological, and histological evidence of chronic HCV. Patients with any other confounding chronic liver disease were excluded. Demographic and laboratory data were collected for each patient at the time of liver biopsy. Data of liver biopsy including degree of activity, stage of fibrosis and degree of steatosis were also collected. Patients with normal ALT were identified and follow up data for ALT were collected to identify those with persistently normal values.

Normal ALT at the time of first evaluation was found in 25 out of 198 patients (12.7%). There was no significant difference between patients with normal ALT and patients with high ALT regarding gender, age at infection time, duration of infection and route of acquisition. Patients with normal ALT had lower AST level (P = 0.0005), lower serum bilirubin (P = 0.01), lower serum iron (P = 0.003) and lower body mass index (P = 0.03). Severe hepatic fibrosis (stage III, and IV) was found in 52/173 (30%) patients with high ALT compared to 6/25 (24%) patients with normal ALT (P = 0.5). Hepatic inflammatory activity was substantially less in patients with normal ALT compared to those with high ALT (P = 0.03). Follow up data for 18 normal ALT patients showed that only 7 (39%) had persistently normal ALT values. Results did not change when comparing those with persistently normal ALT to patients with high ALT.

In summary:

A single normal ALT value at the time of first evaluation is relatively common in chronic HCV patients.

Most patients with a normal ALT value at the time of first evaluation did not have a persistently normal ALT.

Patients with normal ALT (single time or persistently) tended to have lower body mass index and hepatic inflammatory activity but were not less likely to have severe hepatic fibrosis.

A normal ALT in chronic HCV patients should not preclude liver biopsy examination or therapy.