BOF: 3.20
A 46-year-old Caucasian female has been referred by her
GP for investigation of abnormal liver function tests. She has been found to
have an elevated ALT. All other biochemical indices of liver function are
normal. She is known to have type 2 diabetes mellitus (NIDDM). She takes 8
units of alcohol per week; she is not on any drugs.
She is obese; height 1.60 metres weight 110 kgs. Her
waist circumference is 90 cms. Her BP is 140/90. No other abnormalities are
detectable clinically.
She has had an ultrasound scan which is consistent with
steatosis. She is negative for hepatitis B and C viruses; she is negative for
smooth muscle antibodies and antimitochondrial antibodies and has normal
levels of ferritin, caeruloplasmin and alpha 1 antitrypsin.
Her GP wishes to start her on a statin and asks you
whether it is safe to do so. Your reply is:
a)
The patient should have a liver biopsy first and depending on liver
histology a decision may be made.
b)
Statins should not be used until liver biochemistry returns to within
normal limits
c)
There is no evidence that this type of patient is at a higher risk of
statin induced hepatotoxicity and statins may be used
d)
Statins should not be used until the patient has reduced her body
weight to within normal limits
e)
Cardiovascular risk is not increased in these patients and hence
statins are not required
Answer: c)
The patient has abnormal liver function tests with the
main abnormality being raised enzymes. She does not take alcohol in excess and
is not on any drugs thus these are not aetiological agents. She is obese with
abdominal obesity (waist circumference >80 cms in a Caucasian female), she has
hypertension and type 2 diabetes mellitus. Thus she has features of the
metabolic syndrome. The most likely cause of the raised enzymes is
non-alcoholic fatty liver disease (NAFLD). The ultrasound findings together
with the negative liver screen and the risk factors for NAFLD should be enough
evidence to point to this diagnosis without the need for a liver biopsy.
In patients with the metabolic syndrome (see later) the
risk of cardiovascular death is increased and if required treatment with
statins should be given, as there is no evidence that these patients are at
increased risk of statin induced hepatotoxicity.
Metabolic Syndrome
Abdominal obesity (waist > 90 cms male > 80 cms
female-Caucasian)
Together with 2 or more of the following
§
Hypertension
§
Abnormal glucose tolerance
§
Low LDL cholesterol (low density lipoprotein cholesterol)
