Management of Elevated Liver Enzymes with Hypercholesterolemia

Initial Diagnostic Approach

The American Gastroenterological Association recommends that a standard liver aetiology screen should include a complete blood count, comprehensive metabolic panel, hepatitis B and C screening, and other tests to determine the underlying cause of elevated liver enzymes in a young male with hypercholesterolemia 1, 2
The European Association for the Study of the Liver suggests that investigation of the underlying cause of abnormal liver tests is essential, as 84% of abnormal liver tests remain abnormal at 1 month, and 75% remain abnormal at 2 years 1, 2

The American Association for the Study of Liver Diseases recommends a core laboratory panel that includes a complete blood count with differential and platelets, comprehensive metabolic panel with albumin and INR, hepatitis B surface antigen and hepatitis C antibody, and fasting lipid panel to assess for NAFLD and other liver diseases 1, 2, 8

The European Association for the Study of the Liver suggests that NAFLD is the most likely diagnosis in a young male with elevated ALT and hypercholesterolemia, and represents the most common cause of unexplained elevated liver enzymes in developed countries 9, 10, 11
The American Gastroenterological Association recommends using either FIB-4 or NAFLD Fibrosis Score (NFS) as first-line testing for fibrosis risk stratification in NAFLD patients 4, 5

The American Heart Association recommends dietary modification to restrict saturated fat to <7% of total calories and cholesterol to <200 mg/day for patients with hypercholesterolemia 8
The European Association for the Study of the Liver suggests that statins are not contraindicated in NAFLD and may actually be beneficial for cardiovascular risk reduction in this population 9, 10

The American Association for the Study of Liver Diseases recommends urgent referral to hepatology if ALT is >8× ULN or >5× baseline, or if there is evidence of synthetic dysfunction or dilated bile ducts on imaging 3, 6
The European Association for the Study of the Liver suggests that routine referral to hepatology is recommended if there is persistent elevation >2× ULN after 3 months despite addressing modifiable factors 3, 7