Patterns of transaminase elevation in rhabdomyolysis versus acetaminophen toxicity - 08/06/20

Doi : 10.1016/j.ajem.2020.04.061

Kevin F. Maskell ^a, Scott W. Powell ^a, Deanna Willis ^a, Victoria Okhomina ^b, Adam P. Sima ^b, Brandon K. Wills ^a,^{^⁎}
^a Department of Emergency Medicine, Division of Medical Toxicology, Virginia Commonwealth University Health System, Richmond, VA, United States of America
^b Department of Biostatistics, Virginia Commonwealth University Health System, Richmond, VA, United States of America

^⁎Corresponding author at: Division of Clinical Toxicology, Department of Emergency Medicine, VCU Medical Center, Virginia Poison Center, 830 E. Main Street, Suite 300, Richmond, VA 23219, United States of America.Division of Clinical ToxicologyDepartment of Emergency MedicineVCU Medical CenterVirginia Poison Center830 E. Main Street, Suite 300RichmondVA23219United States of America

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Abstract

Background

Transaminase elevations can occur from liver injury or in the setting of rhabdomyolysis. The goal of this study is to evaluate indices that could differentiate acetaminophen toxicity from muscle injury in the setting of transaminase elevations.

Methods

A retrospective chart review of consecutive cases reported to our regional poison center. Patients with transaminase (AST and ALT) elevation were grouped as those with acetaminophen exposure (AT) and those with elevated creatine phosphokinase (CPK) without evidence of acetaminophen exposure (RHB).

Results

Of the 345 patients included in the study, elevated AST/ALT levels were attributed to rhabdomyolysis in 168 patients and attributed to acetaminophen toxicity in 177 patients. The median AST: ALT values also differed between groups, with patients in the RHB group had higher median ratios (p < 0.001). Using an AST: ALT value of 2.02 as a diagnostic cutoff produced a specificity of 0.52 (95% CI: 0.37, 0.64) and sensitivity of 0.84 (95% CI: 0.73, 0.94) for acetaminophen detection in the test dataset (N = 104).

Conclusions

Elevated transaminases due to liver injury from acetaminophen ingestion had a different pattern than elevated transaminases due to rhabdomyolysis. Lower AST:ALT ratios were found in acetaminophen cases, however, the specificity using a ratio threshold of ≤1 would be 83%.

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Keywords : Aminotransferase, Rhabdomyolysis, Acetaminophen toxicity, Transaminase