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Clinical Pearl: Elevated Liver Enzymes and Rhabdomyolysis

doi: 10.1097/01.EEM.0000515677.06929.4e
Clinical Pearl


Many clinicians are unaware that rhabdomyolysis is often associated with elevations of aminotransferases. Elevated AST levels have been observed in 95 percent of rhabdomyolysis cases and elevated ALT in 73 percent. This is consistent with muscle release of AST and ALT, a well-characterized phenomenon. (Mayo Clin Proc 2017;92[1]:e1; J Med Toxicol 2010;6[3]:294.) AST is present in abundance in skeletal muscle, ALT to a lesser extent. Serial AST concentrations fall in parallel with CPK concentrations; ALT does not fall as rapidly as AST and not in parallel with peak CPK.

Elevated aminotransferases in rhabdomyolysis often trigger concern for concomitant hepatic disease resulting in unnecessary investigation. (Mayo Clin Proc 2017;92[1]:e1; J Med Toxicol 2010;6[3]:294; Hepatology 2005;41[2]:380.) Of course, the possibility of a hepatic cause must be considered in each case, but the recognition that abnormal aminotransferases in the context of rhabdomyolysis may not be indicative of hepatic injury may avoid an unnecessary workup.

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