Chronic liver disease (CLD) represents a formidable global health challenge, accounting for approximately 2 million deaths annually [1]. In India, the burden of CLD is particularly pronounced, since an estimated 18.3% of these global deaths were from the country. The spectrum of CLD encompasses diverse aetiologies, including alcoholic liver disease (ALD), non-alcoholic fatty liver disease (NAFLD), viral hepatitis, and autoimmune conditions. Despite advances in diagnostic and therapeutic modalities, CLD remains a leading cause of morbidity and mortality, often progressing insidiously to advanced stages such as fibrosis and cirrhosis [2].

The accurate and timely identification of the underlying cause of CLD is pivotal for guiding management strategies and predicting patient outcomes. However, establishing a definitive diagnosis can be challenging, as the clinical presentation of CLD is often nonspecific and may overlap with other systemic disorders [3]. Additionally, the complex interplay of environmental and genetic factors contributes to the heterogeneous nature of CLD, further complicating diagnostic and prognostic assessments.

The assessment of liver function has a long and evolving history, with early markers such as bilirubin and albumin providing valuable insights into liver health [4]. However, these markers often lacked specificity and sensitivity in detecting early or mild liver damage. The understanding of liver disease took a significant leap forward with the recognition of enzymes as potential indicators of liver injury [5]. In the mid-20th century, the discovery of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) as enzymes predominantly found in the liver paved the way for a more specific and sensitive approach to diagnosing liver diseases7.

In 1955, De Ritis et al. introduced the concept of the AST/ALT ratio, a simple yet powerful tool that revolutionized the interpretation of liver enzyme tests [6]. This ratio, calculated by dividing the serum AST level by the serum ALT level, was initially found to be useful in differentiating between acute viral hepatitis (where ALT is typically higher than AST) and alcoholic hepatitis (where AST is often higher than ALT). This landmark discovery laid the foundation for the widespread use of AST/ALT ratio in the diagnosis and prognosis of various liver diseases.

The present study entitled STUDY OF ASPARTATE TRANSAMINASE: ALANINE TRANSAMINASE RATIO IN PATIENTS OF CHRONIC LIVER DISEASE: An observational study in GWALIOR CHAMBAL REGION will be carried out in the Department of Medicine in J.A. Group of Hospitals, Gwalior on an in and outpatient basis for 02 Years on 100 Patients.

All patients will undergo a detailed clinical examination at admission. Relevant history and physical examination including symptom and signs of liver failure, hepatomegaly, splenomegaly and abdominal vein collaterals will be recorded. Ascites will be graded as none, mild, moderate and severe.

Inclusion criteria:

1. Patients age 18 years and above and DIAGNOSED CASES OF CHRONIC LIVER DISEASE

Exclusion criteria:

1. Patients taking hepatotoxic drugs.
2. Patients suffering from any kind of benign/malignant tumor.

Statistical Analysis

Statistical Analysis shall be done using SPSS 2.0 and graphs shall be generated by Microsoft Excel and Word. A p value of less than 0.05 shall be considered significant.

Table 1: Distribution of patients according to the age group and gender

The distribution of 100 patients across age groups and gender was analyzed. The largest group consisted of males between 41-50 years old (38.4%), while the smallest group was females between 31-40 years old (1.2%). Notably, in the 51-60 age group, the proportion of females (38%) exceeded that of males (16.3%). However, a chi- square test revealed no statistically significant association between age group and gender (χ² = 3.383, p = 0.496), indicating that the observed differences in gender distribution across age groups were likely due to chance.

Table No. 2: Distribution of patients according to the clinical features at presentation

The prevalence of various clinical features among the patient population. Abdominal distension and pedal edema were the most common symptoms, reported by 86% and 81% of patients, respectively. Jaundice was present in 61% of patients, while abdominal pain and breathlessness were noted in 48% and 44%, respectively. Generalized weakness and weight loss were reported by 42% and 34% of patients, respectively. Altered sensorium was less common (24%), and hematemesis, melena, and chest pain were the least frequent symptoms, each affecting 7-8% of patients.

Table No. 3: Distribution of patients with ALD according to the duration since detection of liver disease

The distribution of disease duration for patients with alcoholic liver disease (ALD). The majority of patients (58.9%) were diagnosed within 3-6 years before the study, while 25% had been diagnosed less than 3 years prior. A smaller proportion (16.1%) had been living with ALD for more than 6 years. This suggests that most ALD cases in this sample are identified within a relatively short timeframe after disease onset.

Table No. 4: Distribution of patients according to the findings on LFT and RFT

The assessment of liver and kidney function in 100 patients revealed a wide range of values, indicating varying degrees of organ function. Serum creatinine ranged from 0.00 to 61.00 mg/dL (mean 1.90 mg/dL), while serum urea ranged from 5.0 to 170.0 mg/dL (mean 36.69 mg/dL). Liver function tests also showed variability, with SGOT (AST) ranging from 10 to 435 U/L (mean 89.06 U/L) and SGPT (ALT) from 7 to 395 U/L (mean 52.16 U/L). The SGOT/SGPT ratio varied from 0.159 to 7.222 (mean 2.18). Total bilirubin ranged from 0.33 to 19.51 mg/dL (mean 2.92 mg/dL), while direct bilirubin ranged from 0.05 to 14.20 mg/dL (mean 1.23 mg/dL). Lastly, serum alkaline phosphatase (ALP) showed the widest range, from 14.0 to 709.0 U/L (mean 118.16 U/L). These findings indicate a diverse range of liver and kidney function within the patient population.

Table No. 5: Comparison of mean age of patients belonging to both groups – Alcoholic CLD and Nonalcoholic etiologies of CLD

The mean age of patients with alcoholic chronic liver disease (ALD) and those with non-alcoholic causes of CLD. The mean age of patients with ALD was 45.57 years (SD = 11.92), while the mean age of patients with non-alcoholic CLD was 47.57 years (SD = 13.15). However, the t-statistic of -0.794 and the corresponding p-value of 0.426 indicate that this difference in mean age is not statistically significant.

Table 1: Distribution of patients according to the age group and gender

The distribution of 100 patients across age groups and gender was analyzed. The largest group consisted of males between 41-50 years old (38.4%), while the smallest group was females between 31-40 years old (1.2%). Notably, in the 51-60 age group, the proportion of females (38%) exceeded that of males (16.3%). However, a chi- square test revealed no statistically significant association between age group and gender (χ² = 3.383, p = 0.496), indicating that the observed differences in gender distribution across age groups were likely due to chance.

Table No. 2: Distribution of patients according to the clinical features at presentation

The prevalence of various clinical features among the patient population. Abdominal distension and pedal edema were the most common symptoms, reported by 86% and 81% of patients, respectively. Jaundice was present in 61% of patients, while abdominal pain and breathlessness were noted in 48% and 44%, respectively. Generalized weakness and weight loss were reported by 42% and 34% of patients, respectively. Altered sensorium was less common (24%), and hematemesis, melena, and chest pain were the least frequent symptoms, each affecting 7-8% of patients.

Table No. 3: Distribution of patients with ALD according to the duration since detection of liver disease

The distribution of disease duration for patients with alcoholic liver disease (ALD). The majority of patients (58.9%) were diagnosed within 3-6 years before the study, while 25% had been diagnosed less than 3 years prior. A smaller proportion (16.1%) had been living with ALD for more than 6 years. This suggests that most ALD cases in this sample are identified within a relatively short timeframe after disease onset.

Table No. 4: Distribution of patients according to the findings on LFT and RFT

The assessment of liver and kidney function in 100 patients revealed a wide range of values, indicating varying degrees of organ function. Serum creatinine ranged from 0.00 to 61.00 mg/dL (mean 1.90 mg/dL), while serum urea ranged from 5.0 to 170.0 mg/dL (mean 36.69 mg/dL). Liver function tests also showed variability, with SGOT (AST) ranging from 10 to 435 U/L (mean 89.06 U/L) and SGPT (ALT) from 7 to 395 U/L (mean 52.16 U/L). The SGOT/SGPT ratio varied from 0.159 to 7.222 (mean 2.18). Total bilirubin ranged from 0.33 to 19.51 mg/dL (mean 2.92 mg/dL), while direct bilirubin ranged from 0.05 to 14.20 mg/dL (mean 1.23 mg/dL). Lastly, serum alkaline phosphatase (ALP) showed the widest range, from 14.0 to 709.0 U/L (mean 118.16 U/L). These findings indicate a diverse range of liver and kidney function within the patient population.

Table No. 5: Comparison of mean age of patients belonging to both groups – Alcoholic CLD and Nonalcoholic etiologies of CLD

The mean age of patients with alcoholic chronic liver disease (ALD) and those with non-alcoholic causes of CLD. The mean age of patients with ALD was 45.57 years (SD = 11.92), while the mean age of patients with non-alcoholic CLD was 47.57 years (SD = 13.15). However, the t-statistic of -0.794 and the corresponding p-value of 0.426 indicate that this difference in mean age is not statistically significant.

Our study population predominantly comprised individuals between 41 and 50 years of age (37%), aligning with global trends indicating a higher prevalence of CLD in middle-aged adults. This age distribution is comparable to that observed in Jindal et al. (2020)[7], where the mean age of patients with type 2 diabetes mellitus (a risk factor for CLD) was 54.97 ± 11.90 years. However, it contrasts with the findings of Chowdhury SD et al. (2013)[8], who reported a median age of 43 years in their cohort of NAFLD patients. This discrepancy could be attributed to differences in the underlying etiologies of CLD, with alcohol-related liver disease potentially manifesting earlier than NAFLD.

The most common symptoms observed in our study population were abdominal distension (86%), pedal edema (81%), and jaundice (61%). These findings align with classic manifestations of advanced liver disease, reflecting impaired hepatic function and portal hypertension. Abdominal distension often results from ascites, a common complication of cirrhosis, while pedal edema signifies fluid retention due to hypoalbuminemia and decreased oncotic pressure. Jaundice, the yellowing of skin and eyes, arises from elevated bilirubin levels due to impaired hepatic excretion.

The high prevalence of these symptoms in our cohort is consistent with other studies on CLD. For instance, Kolhe et al. (2019)[9] reported a similar frequency of abdominal distension (86%) in their study on non-alcoholic fatty liver disease (NAFLD), while Gurung et al. (2013)[10] noted jaundice in 61% of their alcoholic liver disease (ALD) patients. However, the incidence of pedal edema in our study was higher than that reported by Aravind et al. (2020)[11], who observed this symptom in only 30% of their ALD patients. This discrepancy could be attributed to differences in disease severity or the presence of coexisting conditions, such as cardiac dysfunction, which can exacerbate fluid retention. The underlying pathophysiological mechanisms of these symptoms are multifaceted.

The laboratory parameters in our study revealed a wide range of values, reflecting the heterogeneity of liver function in CLD patients. The mean AST/ALT ratio was 2.181, consistent with other studies reporting elevated ratios in CLD (Rehman and Sarwar (2006); Lin et al. (2015)[12]). The mean serum ALP was 118.16 U/L, which is within the normal range but can be elevated in cholestatic liver disease or bone disorders. The mean total bilirubin (2.92 mg/dL) and direct bilirubin (1.23 mg/dL) levels were elevated, indicating impaired hepatic excretion of bilirubin, a common feature of CLD[13].

Renal function tests (RFTs) showed a mean serum creatinine of 1.90 mg/dL and a mean serum urea of 36.69 mg/dL, suggesting that a significant proportion of patients had impaired renal function, a frequent complication of advanced liver disease[14]. This observation aligns with the findings of Aravind et al. (2020)101, who reported elevated creatinine levels in patients with alcoholic liver disease.

Prospective studies are needed to investigate the temporal changes in clinical, laboratory, and imaging parameters in patients with different CLD etiologies, allowing for a better understanding of disease progression and prognosis. Given the potential of the AST/ALT ratio as a diagnostic marker, further research is needed to validate its utility in differentiating between different CLD etiologies and predicting disease outcomes.

1. Mondal D, Das K, Chowdhury A. Epidemiology of Liver Diseases in India. Clin Liver Dis (Hoboken) [Internet]. 2022 Jan 28 [cited 2024 May 26];19(3):114–7. Available from: https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC8958241/
2. Sharma A, Nagalli S. Chronic Liver Disease. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 [cited 2024 May 26]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK554597/
3. Wazir H, Abid M, Essani B, Saeed H, Ahmad Khan M, Nasrullah F, et al. Diagnosis and Treatment of Liver Disease: Current Trends and Future Directions. Cureus [Internet]. 2023 Dec 4 [cited 2024 Jun 26]; Available from: https://www.cureus.com/articles/211919-diagnosis-and-treatment-of-liver-disease-current-trends-and-future-directions
4. Williams R. Global challenges in liver disease. Hepatology. 2006 Sep;44(3):521–6.
5. Ramos-Lopez O, Martinez-Lopez E, Roman S, Fierro NA, Panduro A. Genetic, metabolic and environmental factors involved in the development of liver cirrhosis in Mexico. World Journal of Gastroenterology [Internet]. 2015 Nov 7 [cited 2024 Jun 26];21(41):11552–66. Available from: https://www.wjgnet.com/1007-9327/full/v21/i41/11552.htm
6. Mousa OY, Kamath PS. A History of the Assessment of Liver Performance. Clin Liver Dis (Hoboken) [Internet]. 2021 Oct 29 [cited 2024 Jun 26];18(Suppl 1):28–48. Available from: https://www.ncbi.nlm.nih.gov/pmc/ articles/ PMC8555456/
7. Jindal H, Singh A, Goyal R, Kamendu A. Observational Study of Serum Alanine Aminotransferase (ALT), Serum Aspartate Aminotransferase (AST) and Serum Alkaline Phosphatase (ALP) Levels in Type 2 Diabetic Patients. jebmh [Internet]. 2020 Nov 30 [cited 2024 Jun 28];7(48):2852–5. Available from: https://jebmh.com/assets/data_pdf/Himanshu_Jindal--Sadiya--Kru--OA-- Checked.pdf
8. Chowdhury SD, Ramakrishna B, Eapen CE, Goel A, Zachariah UG, Chandramohan A, et al. Fibrosis in non-alcoholic fatty liver disease: correlation with simple blood indices and association with tumor necrosis factor-alpha polymorphisms. Trop Gastroenterol. 2013;34(1):31–5.
9. Kolhe KM, Amarapurkar A, Parikh P, Chaubal A, Chauhan S, Khairnar H, et al. Aspartate transaminase to platelet ratio index (APRI) but not FIB-5 or FIB-4 is accurate in ruling out significant fibrosis in patients with non-alcoholic fatty liver disease (NAFLD) in an urban slum-dwelling population. BMJ Open Gastroenterol [Internet]. 2019 Jun [cited 2024 Jun 28];6(1):e000288. Available from: https://bmjopengastro.bmj.com/lookup/doi/10.1136/bmjgast-2019-000288
10. Gurung RB, Purbe B, Gyawali P, Risal P. The ratio of aspartate aminotransferase to alanine aminotransferase (AST/ALT): the correlation of value with underlying severity of alcoholic liver disease. Kathmandu Univ Med J (KUMJ). 2013;11(43):233–6.
11. A, K. A, Farooq S. A study of alanine aminotransferase - aspartate aminotransferase as a marker of advanced alcoholic liver disease. International Journal of Advances in Medicine. 2020 Mar 5;7.
12. Lin MS, Lin HS, Chung CM, Lin YS, Chen MY, Chen PH, et al. Serum aminotransferase ratio is independently correlated with hepatosteatosis in patients with HCV: a cross-sectional observational study. BMJ Open. 2015 Sep 14;5(9):e008797.
13. Lumongga F, Nur Anggraeni R. Correlation Between Aspartate Aminotransferase/ Alanine Transferase Ratio (AST/ALT Ratio) and Stage of Liver Fibrosis in Patients with Chronic Hepatitis. In: Proceedings of the 1st Public Health International Conference (PHICo 2016) [Internet]. Medan, Indonesia: Atlantis Press; 2017 [cited 2024 Jun 28]. Available from: http://www.atlantis-press.com/php/paper-details.php?id=25875901
14. Lee K, Sinn DH, Gwak GY, Cho HC, Jung SH, Paik YH, et al. Prediction of the Risk of Hepatocellular Carcinoma in Chronic Hepatitis C Patients after Sustained Virological Response by Aspartate Aminotransferase to Platelet Ratio Index. Gut Liver [Internet]. 2016 Sep [cited 2024 Jun 28];10(5):796–802. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5003204/