Mild, asymptomatic elevations of alanine transaminase (ALT) and aspartate transaminase (AST) levels, defined as less than five times the upper limit of normal, are common in primary care. If the elevation persists, hepatic ultrasonography and further testing for uncommon causes should be considered. If testing for common causes is consistent with nonalcoholic fatty liver disease and is otherwise unremarkable, a trial of lifestyle modification is appropriate. The nonalcoholic fatty liver disease fibrosis score and the alcoholic liver disease/nonalcoholic fatty liver disease index can be helpful in the evaluation of mildly elevated transaminase levels. The initial evaluation should include an assessment for metabolic syndrome and insulin resistance (i.e., waist circumference, blood pressure, fasting lipid level, and fasting glucose or A1C level) a complete blood count with platelets measurement of serum albumin, iron, total iron-binding capacity, and ferritin and hepatitis C antibody and hepatitis B surface antigen testing. Extrahepatic sources, such as thyroid disorders, celiac sprue, hemolysis, and muscle disorders, are also associated with mildly elevated transaminase levels. Rare causes include alpha 1-antitrypsin deficiency, autoimmune hepatitis, and Wilson disease. Uncommon causes include drug-induced liver injury, hepatitis B and C, and hereditary hemochromatosis. The most common causes of elevated transaminase levels are nonalcoholic fatty liver disease and alcoholic liver disease. An approach based on the prevalence of diseases that cause asymptomatic transaminase elevations can help clinicians efficiently identify common and serious liver disease. population has elevated transaminase levels. It is estimated that approximately 10% of the U.S. Mild, asymptomatic elevations (less than five times the upper limit of normal) of alanine transaminase and aspartate transaminase levels are common in primary care.

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