Clinical features of hepatitis C–infected patients with persistently normal alanine transaminase levels in the southwestern United States

Approximately one third of patients with chronic hepatitis C virus (HCV) infection have normal alanine transaminase (ALT) levels. We studied the clinical, biochemical, virological, and histological features in patients with persistently normal ALT. A case‐control study was conducted on 275 patients with chronic HCV infection, including 75 patients with persistently normal ALT and 200 patients with abnormal ALT. Persistently normal ALT was defined as 4 consecutive ALT values in each patient within a period of 12 months. The average age of the patients was 44 years (range 18 to 69 years). More non‐Hispanic whites had persistently normal ALT. The mean serum ferritin level was significantly lower in patients with persistently normal ALT as compared with abnormal ALT (128 ± 92 ng/mL and 224 ± 128 ng/mL), respectively (P= .017). The mean HCV‐RNA level was significantly lower in patients with persistently normal ALT as compared with abnormal ALT (12 × 105 ± 2.8 × 106 copies/mL and 33 × 105 ± 8.0 × 106), respectively (P= .02). Histologically, patients with persistently normal ALT had less severe portal inflammation (P< .05), lobular inflammation (P= .003), piecemeal necrosis (P= .002), fibrosis (P< .05), lower prevalence of cirrhosis (P= .007), as well as a slower fibrosis progression rate (P< .001). Chronic hepatitis C patients with persistently normal ALT have low‐activity grade and stage on liver biopsy. In these patients the hepatitis C RNA level was lower compared with abnormal ALT patients, which may explain the slower fibrosis progression rate.