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To the Editor

%We read with interest Puri and Sanyal's article on nonalcoholic fatty liver disease (NAFLD) published in Clinical Liver Disease.1 Because NAFLD has the potential to progress to cirrhosis, hepatocellular carcinoma, and finally death.2 The early identification of persons at risk for NAFLD is of great concern. Although NAFLD is generally diagnosed by ultrasonography, ultrasonography is not always available in primary care settings, particularly in developing areas. Therefore, a simple, sensitive, and noninvasive tool for identifying people at risk for NAFLD would have important clinical value. Recently, Miyake et al.3 reported that serum alanine aminotransferase (ALT) could be used as a surrogate marker for the presence of NAFLD. The optimal ALT cutoff levels in their study population were estimated to be 25 U/ L for men and 17 U/L for women. In a cross-sectional study, we also found that people with ALT levels>40 IU/L were at increased risk for fatty liver (odds ratio52.7, 95% confidence interval51.6-4.6, P<0.001) in comparison with those with ALT levels≤40 IU/L.4 In addition, the majority of those with NAFLD have no clinical symptoms. Similar studies in diverse ethnic populations are needed because the thresholds may be different in racially distinct groups.


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  • 1
    Puri P, Sanyal AJ. Nonalcoholic fatty liver disease: definitions, risk factors, and workup. Clinical Liver Disease 2012; 1: 98102.
  • 2
    Mehta R, Younossi ZM. Natural history of nonalcoholic fatty liver disease. Clinical Liver Disease 2012; 1: 111112.
  • 3
    Miyake T, Kumagi T, Hirooka M, Koizumi M, Furukawa S, Ueda T, et al. Metabolic markers and ALT cutoff level for diagnosing nonalcoholic fatty liver disease: a community-based cross-sectional study. J Gastroenterol 2012; 47: 696703.
  • 4
    Lai SW, Tan CK, Ng KC, Epidemiology of fatty liver in a hospital-based study in Taiwan. South Med J 2002; 95: 12881292.