Previous article
Noninvasive Cardiac Testing
Dec 2024
Next article
Bone Stress Injuries: Diagnosis and Management

Mildly Elevated Liver Transaminase Levels: Causes and Evaluation

Robert C. Langan, MD
Kourtni A. Hines-Smith, MD

American Family Physician. 2024;110(6):585-591.

Author disclosure: No relevant financial relationships.

This clinical content conforms to AAFP criteria for CME.

Approximately 10% to 20% of the general population has elevated liver chemistry levels, including aspartate and alanine transaminases. Elevated transaminase levels may be associated with significant underlying liver disease and increased risk of liver-related and all-cause mortality. The most common causes of mildly elevated transaminase levels (two to five times the upper limit of normal) are metabolic dysfunction-associated steatotic liver disease (MASLD) and alcoholic liver disease. Uncommon causes include drug-induced liver injury, chronic hepatitis B and C, and hereditary hemochromatosis. Rare causes are alpha1-antitrypsin deficiency, autoimmune hepatitis, and Wilson disease. Extrahepatic causes are celiac disease, hyperthyroidism, rhabdomyolysis, and pregnancy-associated liver disease. Initial laboratory testing assesses complete blood cell count with platelets, blood glucose, lipid profile, hepatitis B surface antigen, hepatitis C antibody, serum albumin, iron, total iron-binding capacity, and ferritin. If MASLD is suspected, the FIB-4 Index Score or NAFLD Fibrosis Score can be used to predict which patients are at risk for fibrosis and may benefit from further testing or referral to a hepatologist. All patients with elevated transaminases should be counseled about moderation or cessation of alcohol use, weight loss, and avoidance of hepatotoxic drugs.

ROBERT C. LANGAN, MD, FAAFP, is program director at the St. Luke's Family Medicine Residency-Sacred Heart Campus, Allentown, Penn., and an adjunct professor in the Department of Family and Community Medicine at the Lewis Katz School of Medicine, Temple University, Philadelphia, Penn.

KOURTNI A. HINES-SMITH, MD, is faculty at St. Luke's Family Medicine Residency-Sacred Heart Campus, and an adjunct clinical assistant professor in the Department of Family and Community Medicine at the Lewis Katz School of Medicine, Temple University.

Address correspondence to Robert C. Langan, MD, at robert.langan@sluhn.org.

Author disclosure: No relevant financial relationships.

  1. 1.Kwo PY, Cohen SM, Lim JK. ACG clinical guideline: evaluation of abnormal liver chemistries. Am J Gastroenterol. 2017;112(1):18-35.
  2. 2.Radcke S, Dillon JF, Murray AL. A systematic review of the prevalence of mildly abnormal liver function tests and associated health outcomes. Eur J Gastroenterol Hepatol. 2015;27(1):1-7.
  3. 3.Lominadze Z, Kallwitz ER. Misconception: you can’t have liver disease with normal liver chemistries. Clin Liver Dis (Hoboken). 2018;12(4):96-99.
  4. 4.Lee TH, Kim WR, Benson JT, et al. Serum aminotransferase activity and mortality risk in a United States community. Hepatology. 2008;47(3):880-887.
  5. 5.Kanwal F, Neuschwander-Tetri BA, Loomba R, et al. Metabolic dysfunction-associated steatotic liver disease. Hepatology. 2024;79(5):1212-1219.
  6. 6.Rinella ME, Neuschwander-Tetri BA, Siddiqui MS, et al. AASLD Practice Guidance on the clinical assessment and management of nonalcoholic fatty liver disease. Hepatology. 2023;77(5):1797-1835.
  7. 7.Crabb DW, Im GY, Szabo G, et al. Diagnosis and treatment of alcohol-associated liver diseases: 2019 practice guidance from the American Association for the Study of Liver Diseases. Hepatology. 2020;71(1):306-333.
  8. 8.European Association for the Study of the Liver. EASL clinical practice guidelines: drug-induced liver injury. J Hepatol. 2019;70(6):1222-1261.
  9. 9.Krist AH, Davidson KW, Mangione CM, et al. Screening for hepatitis B virus infection in adolescents and adults: US Preventive Services Task Force recommendation statement. JAMA. 2020;324(23):2415-2422.
  10. 10.Owens DK, Davidson KW, Krist AH, et al. Screening for hepatitis C virus infection in adolescents and adults: US Preventive Services Task Force recommendation statement. JAMA. 2020;323(10):970-975.
  11. 11.Kowdley KV, Brown KE, Ahn J, et al. ACG clinical guideline: hereditary hemochromatosis. Am J Gastroenterol. 2019;114(8):1202-1218.
  12. 12.Strnad P, McElvaney NG, Lomas DA. Alpha1-antitrypsin deficiency. N Engl J Med. 2020;382(15):1443-1455.
  13. 13.Muratori L, Lohse AW, Lenzi M. Diagnosis and management of autoimmune hepatitis. BMJ. 2023;380:e070201.
  14. 14.Roberts EA, Schilsky ML. Current and emerging issues in Wilson’s disease. N Engl J Med. 2023;389(10):922-938.
  15. 15.Mack CL, Adams D, Assis DN, et al. Diagnosis and management of autoimmune hepatitis in adults and children: 2019 practice guidance and guidelines from the American Association for the Study of Liver Diseases. Hepatology. 2020;72(2):671-722.
  16. 16.Lilford RJ, Bentham L, Girling A, et al. Birmingham and Lambeth Liver Evaluation Testing Strategies. Health Technol Assess. 2013;17(28):1-307.
  17. 17.Donnan PT, McLernon D, Dillon JF, et al. Development of a decision support tool for primary care management of patients with abnormal liver function tests without clinically apparent liver disease. Health Technol Assess. 2009;13(25):iii-iv.
  18. 18.Smith A, Baumgartner K, Cooper J, et al. Liver disease: evaluation of patients with abnormal liver test results. FP Essent. 2021;511:11-22.
  19. 19.Younossi ZM, Koenig AB, Abdelatif D, et al. Global epidemiology of nonalcoholic fatty liver disease-meta-analytic assessment of prevalence, incidence, and outcomes. Hepatology. 2016;64(1):73-84.
  20. 20.Basu R, Noureddin M, Clark JM. Nonalcoholic fatty liver disease: review of management for primary care providers. Mayo Clin Proc. 2022;97(9):1700-1716.
  21. 21.Newsome PN, Cramb R, Davison SM, et al. Guidelines on the management of abnormal liver blood tests. Gut. 2018;67(1):6-19.
  22. 22.Abenavoli L, Masarone M, Peta V, et al. Insulin resistance and liver steatosis in chronic hepatitis C infection genotype 3. World J Gastroenterol. 2014;20(41):15233-15240.
  23. 23.Cusi K, Isaacs S, Barb D, et al. American Association of Clinical Endocrinology clinical practice guideline for the diagnosis and management of nonalcoholic fatty liver disease in primary care and endocrinology clinical settings. Endocr Pract. 2022;28(5):528-562.
  24. 24.Kanwal F, Shubrook JH, Adams LA, et al. Clinical care pathway for the risk stratification and management of patients with nonalcoholic fatty liver disease. Gastroenterology. 2021;161(5):1657-1669.
  25. 25.Cleveland E, Bandy A, VanWagner LB. Diagnostic challenges of nonalcoholic fatty liver disease/nonalcoholic steatohepatitis. Clin Liver Dis (Hoboken). 2018;11(4):98-104.
  26. 26.Leoni S, Tovoli F, Napoli L, et al. Current guidelines for the management of non-alcoholic fatty liver disease: a systematic review with comparative analysis. World J Gastroenterol. 2018;24(30):3361-3373.
  27. 27.Harrison SA, Bedossa P, Guy CD, et al.; MAESTRO-NASH Investigators. A phase 3, randomized, controlled trial of resmetirom in NASH with liver fibrosis. N Engl J Med. 2024;390(6):497-509.
  28. 28.Westfall E, Jeske R, Bader AR. Nonalcoholic fatty liver disease. Am Fam Physician. 2020;102(10):603-612.
  29. 29.Singal AK, Mathurin P. Diagnosis and treatment of alcohol-associated liver disease: a review. JAMA. 2021;326(2):165-176.
  30. 30.Wang J, Li P, Jiang Z, et al. Diagnostic value of alcoholic liver disease (ALD)/nonalcoholic fatty liver disease (NAFLD) index combined with γ-glutamyl transferase in differentiating ALD and NAFLD. Korean J Intern Med. 2016;31(3):479-487.
  31. 31.National Institute of Diabetes and Digestive and Kidney Diseases. LiverTox: Clinical and research information on drug-induced liver injury. Updated September 16, 2024. Accessed October 21, 2024. https://www.ncbi.nlm.nih.gov/books/NBK547852/
  32. 32.Wilkins T, Sams R, Carpenter M. Hepatitis B: screening, prevention, diagnosis, and treatment. Am Fam Physician. 2019;99(5):314-323.
  33. 33.Maness DL, Riley E, Studebaker G. Hepatitis C: diagnosis and management. Am Fam Physician. 2021;104(6):626-635.
  34. 34.Kane SF, Roberts C, Paulus R. Hereditary hemochromatosis: rapid evidence review. Am Fam Physician. 2021;104(3):263-270.
  35. 35.Aggarwal M, Garg R, Kumar P, et al. Bi-directional relationship between celiac disease and liver chemistries: a systematic review and meta-analysis. Dig Dis Sci. 2023;68(4):1369-1380.
  36. 36.Scappaticcio L, Longo M, Maiorino MI, et al. Abnormal liver blood tests in patients with hyperthyroidism. Thyroid. 2021;31(6):884-894.
  37. 37.Maskell KF, Powell SW, Willis D, et al. Patterns of transaminase elevation in rhabdomyolysis versus acetaminophen toxicity. Am J Emerg Med. 2021;44:362-365.
  38. 38.Kushner T, Park C, Masand D, et al. Prevalence of elevated alanine aminotransferase (ALT) in pregnancy. Medicine (Baltimore). 2022;101(40):e30408.
  39. 39.Oh RC, Hustead TR, Ali SM, et al. Mildly elevated liver transaminase levels: causes and evaluation. Am Fam Physician. 2017;96(11):709-715.
  40. 40.Oh RC, Hustead TR. Causes and evaluation of mildly elevated liver transaminase levels. Am Fam Physician. 2011;84(9):1003-1008.
  41. 41.Giboney PT. Mildly elevated liver transaminase levels in the asymptomatic patient. Am Fam Physician. 2005;71(6):1105-1110.
Previous article
Noninvasive Cardiac Testing
Dec 2024
Next article
Bone Stress Injuries: Diagnosis and Management

Current issue

May 2026

May 2026

Copyright © 2026 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. See permissions for copyright questions and/or permission requests.