Letter to the Editor
Secondary hypertransaminasemia to macro-aspartate aminotransferase
Hipertransaminasemia secundaria a macroaspartato aminotransferasa
Vanesa Crujeiras Martínez
, Rebeca Saborido Fiaño, Nazareth Martinón Torres, Rosaura Leis Trabazo
Corresponding author
Unidad de Gastroenterología, Hepatología y Nutrición Pediátrica, Complexo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
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The patient was referred to Gastroenterology and Pediatric Hepatology for hypertransaminasemia study completion. The girl was asymptomatic, did not report abdominal pain, asthenia or muscle weakness. She had normal bowel habits and from an anthropometric point of view she had a height to weight ratio within −0.5<span class="elsevierStyleHsp" style=""></span>DE for her age.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Physical examination showed good general condition, she was well hydrated, with adequate skin and mucous membrane color. Cardiac auscultation showed rhythmic heartbeats, with no relevant murmurs. Pulmonary auscultation was normal. The abdomen was soft, depressible, painless; there were no palpable masses, hepatomegaly or splenomegaly. From a neurological point of view there were no focal neurological signs, with preserved and symmetrical sensitivity and strength.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The CBC showed figures within the limits of normal hemoglobin, platelet and leukocyte levels. Serum biochemistry showed persistent increased GOT (447 and 510<span class="elsevierStyleHsp" style=""></span>UI/l) in the various analytical controls carried out for 14 months, with normal levels of GPT, GGT, bilirubin, albumin, amylase, lipase and alkaline phosphatase. Renal function and coagulation showed no abnormalities. The determination of immunoglobulins, plasma copper, ceruloplasmin, iron metabolism and alpha-1-antitrypsin was within normal levels. Celiac disease antibodies and determination of ANA, AML, anti-LKM and anti-SLA autoantibodies, as well as the hepatotropic virus serology, were negative. She underwent an abdominal ultrasound, which showed a normal liver structure and echogenicity.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Other extrahepatic causes of high aspartate aminotransferase (AST) were excluded, including hemolysis, myopalthy, thyroid disease and extreme exercise as she had normal levels of CK, LDH and aldolase B at rest as well as normal levels of thyroid hormones.</p><p id="par0030" class="elsevierStylePara elsevierViewall">To study the presence of macro-AST macroenzyme, AST activity was assessed in the supernatant after precipitation with polyethylene glycol. AST activity decreased to 8%, confirming the suspected diagnosis.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Macroenzymes are complexes formed by binding of enzymes such as amylase, creatine kinase, alkaline phosphatase and AST to plasma proteins such as immunoglobulins G, A or beta-lipoproteins, forming soluble macromolecular complexes, with a high molecular weight and a longer half-life compared to the unbound enzymes.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">3,4</span></a> The formation of these immune-enzyme complexes is not associated with any specific disease. However, their presence may lead to increased serum levels of the enzyme isolated and persistent, leading to misdiagnosis and unnecessary tests.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Macro-AST should be suspected in case of hypertransaminasemia with persistent increased AST in a patient with no further abnormalities in liver function, with normal serum levels of ALP, GGT, alkaline phosphatase and muscle enzymes. Diagnosis requires demonstration of complex macro-AST in serum by direct methods for separating serum proteins depending on their molecular weight. It has been determined in the laboratory by polyethylene glycol precipitation methods, thermal stability of IgG-AST, immunoelectrophoresis or gel filtration chromatography.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> Macrocomplex precipitation with polyethylene glycol and the subsequent AST activity determination in the supernatant is a simple method, often used in diagnosis.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Macro-AST detection is not a transitory phenomenon, existing references in the medical literature that reflect the persistence of this finding in patients over 10 years.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> The absence of disease over a long monitoring period in these patients calls for the benign nature of this phenomenon.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">7,8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Therefore, since the macro-AST is a rare biochemical abnormality and is a benign process not requiring treatment, diagnosis interest lies in distinguishing it from other causes of hypertransaminasemia, in order to avoid unnecessary additional diagnostic tests.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Crujeiras Martínez V, Saborido Fiaño R, Martinón Torres N, Leis Trabazo R. Hipertransaminasemia secundaria a macroaspartato aminotransferasa. Endocrinol Nutr. 2015;145:323–324.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evaluation of abnormal liver enzyme results in asymptomatic patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D.S. Pratt" 1 => "M.M. 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