Kotoh et al used the ratio of the serum ALT to LDH in a patient with acute hepatitis to identify a patient who may progress to fulminant hepatic failure. This can help separate a patient who can be managed conservatively from one who requires a liver transplant. The authors are from Kyushu University in Japan.

Patient selection: severe acute hepatitis (serum ALT > 1,000 IU/L or PT/INR > 1.5 on admission)


Patient selection:

(1) serum ALT in IU/L

(2) serum LDH in IU/L

(3) mean of the normal reference range for serum LDH


ALT to LDH index =

= (serum ALT) / ((serum LDH) - (mean of the normal reference range for LDH))



• The paper uses the median of the normal reference range. Since the normal reference range should follow a normal Gaussian distribution then the mean can be substituted.



• A patient with an index > 3 on day 3 after admission can usually be managed conservatively.

• The index tends to increase between admission and day 3 of hospitalization in patients who can be managed conservatively.

• The index does not increase or only slightly in a patient who develops fulminant disease requiring liver transplantation.



• An index > 3 had a sensitivity of 75% and specificity of 100% for predicting conservative management.



• The methods used to measure the serum ALT and LDH were not stated.

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