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ANNALS OF GASTROENTEROLOGY & HEPATOLOGY

Serum ALT Levels in a Cohort of Healthy Blood Donors and Volunteers from Saudi Arabia: The Influence of Sex and Body Mass Index
Hisham O Akbar and Hind I Fallatah

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Affiliation : King Abdul Aziz University Hospital, Jeddah, Saudi Arabia

A B S T R A C T
Serum alanine aminotransferase (ALT) is the most sensitive biochemical marker of hepatocellular injury. The internationally accepted normal level for ALT is 30 U/L in males and 19 U/L in females. Body mass index (BMI) and sex have a significant influence on the ALT levels. Design: Prospective study. Aim: To define the normal serum ALT level in a local population compared to the local reference laboratory value and to determine the influence of sex and BMI. Study population: Group 1, healthy male blood donors; Group 2, healthy female blood donors and healthy female volunteers. Method: We obtained all participant data: age, sex, and nationality and we measured the BMI. We obtained blood samples for the measurement of ALT, complete blood count, and serum lipids. In addition to serology for hepatitis B and C viruses and HIV in the two groups and polymerase chain reaction (PCR) for these three viruses in all blood donors. We also determine the ABO blood group of all donors. Results: We included 131 males in the final analysis for Group 1, in which 75 (57.3%) were Saudis. The mean age was 30.09 years (17–56), the mean BMI was 30.44, and the mean serum ALT was 41.62 U/L (95% CI 43.44–45.25). In Group 2, there were 54 females, including 16 blood donors, 17 healthy females seen for screening, and 21 volunteers, out of which 37 (68.5%) were Saudis. The mean age was 32.32 years (17–69), the mean BMI was 24.867, and the mean serum ALT level was 28.48 (95% CI 26.49–30.47). The difference in serum ALT levels between males and females was statistically significant with a p-value of <0.001 and 0.001 for comparisons between all of Group 1 and 2 and between normal BMI males and females, respectively. For both groups, higher BMI was associated with a higher serum ALT level Pearson correlation 0.442 p = <0.001. In conclusion, the normal serum ALT level is lower than the locally accepted laboratory reference values for both males and females. Sex and BMI are main factors that influence the serum ALT level. Revision of the locally accepted serum ALT level is needed to have better assessment and monitoring for liver disease patients. Keywords: Correspondence: Dr Hisham O Akbar, Consultant Gastroenterologist & Hepatologist, King Abdul Aziz University Hospital, PO Box 80215, Jeddah 21589, Saudi Arabia. Tel: +966-26408435; Fax: +966-26751149; e-mail: gihepa@yahoo.com

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INTRODUCTION
Alanine aminotransferase (ALT) is the most sensitive biomarker for hepatocellular injury. It is found in the hepatic cytosol, and its concentration in extrahepatic tissue is low compared to serum aspartate aminotransferase (AST).1 Normal serum ALT in a selected population varies according to age, sex, and ethnic origin.2 Similar to other biochemical parameters, the normal level of serum ALT was determined in the 1950s3 and was then adjusted by biochemical laboratories based on testing the healthy population of both sexes. In Saudi Arabia, the normal biochemical marker levels were last revised by testing university students in 1982.4 In 2002, Prati et al. in a study from Italy defined new normal levels for serum ALT in a healthy population by testing 6835 healthy blood donors,5 but these results have only been widely accepted over the past few years. In that study the serum ALT level was found to be

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directly related to sex and body mass index (BMI). No similar data are available among Saudis. Similar to other parts of the world, obesity and metabolic syndromes are increasingly recognized among Saudis and other Asians.6–8 On the other hand, chronic viral hepatitis B and C are highly endemic in this part of the world.9 Because persistently elevated ALT warrants additional workup for liver disease,10,11 a more precise definition of normal ALT levels may be needed not only to recognize liver injury but also to avoid unnecessary medical testing and treatment in healthy individuals. Genetic differences among Saudis are also expected to influence serum ALT levels and other biochemical markers. In this study, we tested healthy Saudi and Asian blood donors and volunteers to define the normal serum ALT level in comparison to upper limit of normal local reference laboratory values. In addition, we evaluated the effects of sex, BMI, age, and ABO blood group on the serum ALT levels.

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The inclusion criteria for the healthy female blood donors in Group 2 were similar to those for Group 1. Month 2010 2 www. no recent travel to malaria endemic areas.) or less – – I II III Increased High Very high Extremely high Women >88 cm (35 in. HCV.0† Disease risk for type 2 diabetes. underweight. height.9 35. healthy female volunteers who were primarily doctors at the house officer or resident levels. 3. The laboratory reference normal values at our center for ALT are 30–65 U/L. chronic respiratory disease. Serology for hepatitis B virus (HBV. HCV. BMI was then calculated by the formula (weight/[height in meters]2 ) and categorized as 1. no history of tattoo. nonhypertensive. 000:(000). 5. deficiency virus (HIV).0 – 34.org. Classification of Overweight and Obesity by BMI. Serum ALT was measured using the Dimension clinical chemistry system (Flex reagent cartridge).Annals of Gastroenterology & Hepatology METHODS Aim The aim is to define normal serum ALT levels compared to the locally accepted reference values and to study the effects of sex.) Women 88 cm (35 in. Selection Criteria We obtained official agreement of the blood bank director in the hospital and the blood bank members to conduct the study for Group 1 male and Group 2 female blood donors at the blood bank. ABO blood group. hepatitis C virus (HCV. Candidates who had evidence of nonalcoholic steatohepatitis (NASH) as reflected by elevated ALT above the upper Study Design This was a prospective study conducted at King Abdul Aziz University Hospital. Waist Circumference. IV drug abuse. and healthy females seen for screening at King Abdul Aziz University Hospital. CBC.caloriecontrol. All donors gave signed consent for donation and for the study. and HIV was carried out (Roche Amplicor). 4. Permission to reprint information in whole or in part contained on this site is granted. this method uses the Flex reagent cartridge. We obtained blood samples for blood grouping and a complete blood count (CBC).9 30. class I obesity. and CVD.5 18.9 40. provided customary credit is given. Agreement was also obtained from the other participants for inclusion in the study.com Annals of Gastroenterology & Hepatology agh000002 3/9/2010 17:48:34 . and autoimmune diseases) and negative family history for liver disease. and HIV was evaluated by ELISA. Group 2 was made up of healthy female blood donors. or direct contact with patients with chronic viral hepatitis or human immune Table 1. had a negative history of liver disease. no history of alcohol intake. a negative history of jaundice in the past. the plasma sample and the reagent are delivered to the system that automatically process the sample and deliver the results. hypertensive. sex. Jeddah. All of the included nondonor females were nondiabetic. nationality. and Associated Disease Risks Disease Risk∗ Relative to Normal Weight and Waist Circumference Men 102 cm (40 in.) – – High Very high Very high Extremely high BMI (kg/m2 ) Underweight Normal Overweight Obesity Extreme obesity ∗ † Obesity Class <18.5 – 24. and HIV (evaluated HIVAb by ELISA and polymerase chain reaction [PCR]). the age and nationality were recorded for each subject as well as the BMI in a similar way to Group 1. hypertension. and ethnic origin on serum ALT levels. and lipids were measured as for Group 1 and the serology for HBV. after calibration. even in persons of normal weight. The serum ALT. for the past 2 months before inclusion.slm-journals. 5 Study Population Group 1 includes healthy male blood donors from the blood bank at King Abdul Aziz University Hospital. Source: National Heart. http://www. evaluated hepatitis C virus antibodies by HCVAb ELISA). Increased waist circumference can also be a marker for increased risk. from June 2008 to February 2009. or hyperlipidemic and if they had a negative history of recent acute viral illness. normal. which should be normal with hemoglobin of 12 g/L or more as well as serum lipids. including antibiotics. and weight. PCR testing for HBV. Lung and Blood Institute. or 6. and were not on any medication that can cause abnormal liver enzymes at the time of obtaining the serum ALT levels. For the rest of Group 2. class II obesity.9 25. Inclusion Criteria Group 1 male donors were included if they were not diabetic.0 – 39. All the included candidates in both groups had negative history of chronic diseases (like cardiac and renal failure. AGH 2010. no recent use of hepatotoxic medications. class III morbid obesity (Table 1) for BMI classification. For all donors we obtained data for age. BMI. and no blood transfusions during the past year before the study. evaluated hepatitis B surface antigen by HBSAg ELISA). age. 2.0 – 29. Jeddah. and nonhyperlipidemic. In addition.) or less Men >102 cm (40 in. overweight.

An independent t-test was use to compare ALT levels in males and females and to correlate the mean ALT levels to nationality as Saudi or non-Saudi.8) for 28 females with normal BMI and 3 underweight females. and the Pearson correlation of serum ALT (U/L) and BMI (kg/m2 ) was 0. and 21 volunteer medical staff. Linear regression analysis was used to determine the effect of age on ALT levels.23 (95% CI 34.867 (16. with a p-value of 0.71–40.46–44) for 21 males with normal BMI.com 3 AGH 2010. with a p-value of 0. Month 2010 Annals of Gastroenterology & Hepatology agh000002 3/9/2010 17:48:34 .02) (see Table 2 for demographic data).97 – 51. standard deviations.62 – 45.49 – 30.3 100. The majority of Group 1 (59%. 6). 8 Higher MBI was associated with higher serum ALT for all the 185 participants in the two groups Pearson correlation Table 2. All of the blood donors were also negative for these three viruses by PCR. Demographic Data for Group 1 and 2 Group Mean Age in Years and the Range 30.02) 24. In Group 2. The Pearson correlation of serum ALT (U/L) and BMI (kg/m2 ) was 0. while 17 females were non-Saudis and 15 (27. The mean serum ALT for males was 43.09 years (17–56).012 (Table 5). Table 3.44 U/L (95% CI 41.32 (17 – 67) Ethnic Groups Asian 54 (44. There were 151 male donors who fulfilled the inclusion criteria for Group 1. Multivariate analysis was used to determine the effects of BMI and sex on serum ALT levels. There were 75 (57. higher BMI was associated with higher serum ALT levels.867 kg/m2 (16. the mean serum ALT was 39. 3 had AB+.81–28.53%) 2 (2.97–51.0 Statistical Analysis We used the Statistical Package for Social Science (SPSS) system 15 and obtained means. and HIV.48 U/L (95% CI 26. there were 54 female subjects included in the analysis: 16 blood donors.6 2. while it was 26.5%) Saudis.47 Mean BMI (kg/m2 ) and the Range 30 (16. 45%) had blood group O+ (Table 3).44).0 31. There were 37 (68.62–45. 17 healthy females seen for screening.3 13.09 (17 – 56) 32. 5. 18.5 2. and 1 had O−. Similar to Group 1. 7 CI 0.48 41.252.44 28.7%) Group 1 131 males Group 2 54 females www. We also used correlation analysis for serum ALT and BMI in both Group 1 and 2. HCV. Only 22 females were tested for ABO blood group.27%) were of other Asian origins. Relation of serum ALT to BMI for all the participants in both groups.44) 95% CI ALT U/L 40 30 20 10 0 Under weight Normal Over weight Obesity Very high Morbid obesity BMI class 6 Figure 1. Their mean BMI was 31.25 26. 54 (44. of the remaining 56. The difference in serum ALT between Group 1 and 2 was statistically significant (p-value <0. 60 50 RESULTS All of the participants did not have clinical evidence for liver disease or other chronic illness.308. Males with a higher than normal BMI had significantly higher serum ALT levels compared to males with a normal BMI.001). Twenty male donors were excluded because they had possible NASH.002 (Table 4). and lipids and negative serology for HBV. and frequencies. We used one-way ANOVA to test the relationship between ABO blood group and serum ALT.3 1.81 (95% CI 24.slm-journals. The mean serum ALT for Group 2 was 28.0 4.77%) ALT U/L and 95% CI ALT 95% CI 43. 3 had A+.3%) Saudis. 000:(000). They also had normal CBC. Blood Group Categories for Group 1 Participants Type of Blood Group O+ A+ B+ O− A− B− AB+ Total Number of Blood Donors 59 41 17 6 3 2 3 131 Percent 45. 16 donors and 6 healthy volunteers. The mean age for Group 1 was 30.44 kg/m2 (16.25). 5 had B+.85 U/L.91 (categories 4. and the mean serum ALT was 99.77%) were of other Asian origins.32 years (17–69) and the mean BMI was 24. On subgroup analysis of ALT according to BMI. and the majority (10.5%) Egyptian 2 (1.Serum ALT levels in a cohort of healthy blood donors and volunteers from Saudi Arabia normal laboratory reference value and obesity class 4–6 were excluded.49–30. the difference 9 Saudis 75 (57. similarly.5%) had blood group type O+.27%) 15 (27.422 and p = <001 (Figure 1). blood sugars. The mean BMI for Group 1 was 30.3%) 37 (68. The mean age for Group 2 was 32.47).71 – 40.

184 F value 1. four BMI categories were used for both sexes.76% 16.66% 22.03% 38.12. Piton et al.82 Mean ALT between groups p-value 0. we found that the mean and the upper limit of normal-range serum ALT levels among our cohort of healthy people from Saudi Arabia are lower than the local reference laboratory values. respectively.5% 16.14 In 1998.034 F value 2.2 In 1999. The ALT levels for females with obesity category II and III were combined because only one female in our cohort had morbid obesity category III. The p-value was 0. sex.001).44 ± 1.22% 1.831 for Group 1 and 2. 000:(000).13% 14. respectively.99 Mean ALT between groups p-value 0.85% 100% † Mean Serum ALT U/L and 95% CI ∗ 27. Lower age was associated with lower serum ALT that was not statistically significant on the regression analysis. Month 2010 4 www.8267 35. In that study.Annals of Gastroenterology & Hepatology Table 4.2876 24 ± 6.93% 22.607 for both Group 1 and 2. and for males according to BMI as 43 U/L and 66 U/L for BMI <23 kg/m2 and ≥23 kg/m2 .63% 100% Mean Serum ALT U/L and 95% CI 37. sex. but in that study the ULN was defined for females according to BMI as 32 U/L and 45 U/L for BMI <23 kg/m2 and ≥23 kg/m2 .8 IU/L. from France studied 1033 male and female blood donors and reported similar findings.slm-journals.48 ± 1.5% 7.72 for both groups together and 0.12–15 By using the Olympus AU510 analyzer. respectively. respectively. reported a significant correlation between serum ALT levels to BMI. In 1995. and age. showed similar outcomes. BMI and Mean INTcol="2" ALT Levels for Group 1 BMI Category ∗ Number and Percent 1 21 51 29 19 10 131 0. † Group 1 volunteers with a BMI in categories 3 and 4 had comparable mean ALT levels. Ramesh et al.344 and 0. with a mean ALT level of 21. Similar findings have been reported by several previous studies.3333 ± 16. and age.5.8 ± 6.7512 43.313 43.869).5 ± 5. There were only four underweight participants in both groups and the difference in serum ALT levels between normal and underweight participant for both groups together was not significant (p = 0.0324 31.4502 28. Prati et al. from India also showed lower levels of serum ALT compared to the reference ULN in normal blood donors and emphasized the importance of MBI-adjusted ALT levels among blood donors.602 and 0. Leclercq et al.1429 ± 2. Sex and BMI were the main factors affecting serum ALT levels in those healthy people (Table 6) for linear regression analysis of ALT.2646 46 ± 6.8889 ± 8. DISCUSSION In this study. was statistically significant between males with normal BMI and females with normal BMI (p-value = 0. respectively. There was no relationship between ALT levels and nationality (Saudi or non-Saudi).502 1 Underweight 2 Normal † 3 Overweight 4 Obesity I 5 Obesity II 6 Obesity III (morbid obesity) All Group 1 ∗ BMI categories 1 and 2 were merged because only one male volunteer had a BMI in category 1 (below normal).703% 18.com Annals of Gastroenterology & Hepatology agh000002 3/9/2010 17:48:34 . p = 0. define the upper limit of normal serum ALT among the healthy males as 30 U/L and the upper limit of normal for healthy females 19 U/L. but we did not find a significant relation between ALT levels and ABO blood groups.7865 47. p-value = 0.55% 53. BMI.579 ∗ † Patients with low BMI had ALT level comparable to females with a normal BMI. The results of Prati’s study are currently widely accepted and have been adopted by the major international liver association and guidelines. Table 5.15 In the most recently 10 11 12 AGH 2010.13 Many other studies before Prati et al.401 and 0. The relationship between serum ALT and blood group was tested for participants of Group 1 and 2. BMI Category and Mean ALT Levels for Group 2 BMI Category 1 Underweight 2 Normal 3 Overweight 4 Obesity I 5 Obesity II 6 Obesity III (morbid obesity) All Group 2 Number and Percent 3 29 10 9 12 1 54 5.5±2.328 for both Group 1 and 2.

000 Dependent variable: ALT. since most of the treatment guidelines for such liver diseases suggest elevated ALT for the start of treatment.3% of females were obese. the mean serum ALT level was 37.. Dufour et al. Al-Nozha et al. in which 17 496 normal people were evaluated in 2006. In our study the association between lower ALT and younger age was less evident. reported a prevalence of overweight subjects of 42. this may be due to the selection bias since most of the participants in our study were of younger age and they had close range of age.4%) are non-Saudis resident in the country.9% of males and 18. in 2005 reported a similar association between serum ALT and age group (<40. other genetic factors. and this high rate of obesity at a young age may predict increasing metabolic syndromes and NASH in the future. which are the main risk factors for nonalcoholic fatty liver disease (NAFLD) and metabolic syndromes.17 Elinav et al. This will ultimately lead into more accurate diagnosis and follow-up of liver disease patients locally.com 5 AGH 2010. so similar results for age categories was not obtained in our study.4% obese subjects among males and 44% obese subjects among females in Saudi Arabia.16 Piton et al. and elevated ALT could be explained by obesity and insulin resistance. the relationship between ABO blood group and serum ALT levels has not been addressed.000 0.077 0.449 0. In the studies by Prati et al. in the selection of our studied participant. in their report from the eastern region of the country. the decision to start patients with CHB.6 A lower rate of overweight and obese subjects in Group 2 in our study can be explained by selection bias because more than one-third of the participants in Group 2 were volunteers with normal or close to normal BMI. BMI-based screening serum of ALT levels is needed. 000:(000).20. found a significant effect of obesity and sex on ALT level.851 1. all of the participants were over 17 years of age and only 14 males from Group 1 and 13 females from Group 2 were over 40 years.slm-journals.2% among males and 31. It will help to avoid unnecessary and extensive testing for possible liver disease in healthy individuals. also reported higher ALT levels in African American males but not females. Sex and Age Model Unstandardized Coefficients B Std. 5. for example. in 2000 found that serum ALT gradually increased from childhood until 40 years of age and then began to decline. in addition to that. Different upper limits of serum ALT in our study compared to other studies may be due to different prevalence of obesity. On the other hand.5 (20.989 −12.058 −0.000 0. Kariv et al.443 4. however. and Kariv et al. 1 Constant Sex Age Body mass index −0. out of 27 million of the estimated country population.18 In our study. Most of our studied population was below 35 years old in Group 1 and 2. The findings from our study reflect the need for more accurate definition of normal ALT among the local population in Saudi Arabia because most of the local laboratories are still using the old definition of the upper limit of normal for the serum aminotransferases.7 Similarly.Serum ALT levels in a cohort of healthy blood donors and volunteers from Saudi Arabia Table 6.472 −0. showed a higher prevalence of obesity among females. we found that ABO group had no significant association with serum ALT levels.758 3. Al-Baghli et al. The serum ALT level was highest in the age group of 40–55 years compared to the other two groups.22 Given the increasing prevalence of obesity and metabolic syndromes in Saudi Arabia. along with 26.255 −0.8% among females. published study by Kariv et al. Dufour et al. The ethnicity of the Saudi population is a mixture of Arab.046 0. and 56–17 years).21 We have reported higher rates of overweight and obese subjects in Group 1 compared to Group 2: 38. while 53% of males and 20. also reported a significant association of serum ALT with age. Asian.19 For that reason. The limitations of our study include the small sample size but this was partially due to the inclusion criteria that exclude diabetics (about one-third of the population in the country) and those with personal or family history of liver disease because 2–3% are CBH carriers (200 blood donors were found to be positive for HBV in our blood bank in the year 2008) of. mostly Asians and Egyptians. Error 43.13. which is endemic in the country or autoimmune hepatitis on treatment. Multivariate Analysis for the Serum ALT Levels with the BMI.12.748 0.282 −0.245 9. 40–55. Another limitation point was the small number of participants in Group 13 14 15 www. in our study. We excluded 20 donors because they had NASH.118 Standardized Coefficients Beta t Sig. Month 2010 Annals of Gastroenterology & Hepatology agh000002 3/9/2010 17:48:34 . and Piton et al.17 no similar relationship was found in our study between ALT and nationality (Saudis or non-Saudi).5 U/L compared to a reference ULN of 52. maybe because of less prominent age difference between the participants.5% of females were overweight. the non-Saudis were not excluded so that we can obtain a near accurate serum ALT level that reflects the local population demography figure.23 Standardized values for different laboratory methods of testing serum ALT may be an important target for future studies so that different laboratories around the world can reflect similar or identical values for ALT levels. and differences in the laboratory methods used to determine ALT level. the definition of lower serum ALT levels will affect the management of many patients with liver disease in the country as.693 0. and African origins.068 −7. Similar to our findings.

Wroblewski F. Lott JA. 2010. Choudhury N. Liaw YF. Al-Nozha MM. 2008.26: 824–829. Han KH. AASLD Practice guidelines Chronic hepatitis B: update 2009. Gastroenterology. 17. 2006. 1955. 2007. Gastroenterology. 1982. Scand J Gastroenterol. et al. Performance characteristics of laboratory tests. Ann Intern Med. 2005. El-Zubaier AG. 1999.2:263–283. director of the blood donation area. Yonsei Med J. Re-evaluation of serum alanine aminotransferase upper normal limit and its modulating factors in a large-scale population study. Liver Int.27: 1213–1219. Flamm S. Karmen A. Beth-Or A. 000:(000). Mr.com Annals of Gastroenterology & Hepatology agh000002 3/9/2010 17:48:34 . 10. Demographics of Saudi Arabia. 2. Leclercq I. BMJ. CONCLUSION We have shown that the normal serum ALT levels after excluding occult chronic liver disease are lower than what is currently reported in laboratory reference ranges in a cohort of 185 Saudi men and women blood donors and volunteers. sex and age on serum alanine aminotransferase (ALT) level in healthy blood donors.29:1319–1325. 2004. N Engl J Med. 4. El-Hazmi MA. Kaplan MM. Mrs. and Mr. Al-Turki KA. Choi KS. American Gastroenterological Association (APA.Annals of Gastroenterology & Hepatology 2 compared to Group 1. De Bruyere M. Asian-Pacific consensus statement on the management of chronic hepatitis B: a 2008 update. Alvarez F.100(10):2201–2204. Khalil MZ. Hepatology. Obesity is the only independent factor associated with ultrasound-diagnosed non-alcoholic fatty liver disease: a cross-sectional case-control study. Jee SH. Kim DJ.328:983. Available from Wikipedia. Gupta RK.342:1266–1271. Correlation between serum alanine aminotransferase activity and age: an inverted U curve pattern. 19. Green R. The third point is that the majority of Group 2 participants had normal or just above normal BMI that makes the relation of BMI to serum ALT less prominent compared to males and reflects less rate of obesity in female in Saudi Arabia compared to the previous studies. Acknowledgments: The authors would like to the thank Dr. Bashawri LA. 16. Seeff LB. Taioli E.50: 227–224. AGA technical review on the evaluation of liver chemistry tests. 23. Horsmans Y. Obesity in Saudi Arabia. Month 2010 6 www. Suh I.45:507–539. director of the chemistry laboratory at KAUH. Al-Faleh FZ. J Clin Invest. 22. Clinical Lab Hematology. REFERENCES 1. Fawaz NA. modification of BMI and sexadjusted cut-off ALT levels used in clinical practice will reflect these differences and will influence the management of liver disease.34:323–332. Leshno M. the free encyclopedia. Koff RS. Hashim Sindi. Berg PA. Mr. LaDue JS. Trop Geogr Med. the blood bank director at KAUH. Am J Gastroenterol. I. Abdulsalam. 1999. Acta Gastroenterol Belg. 8. Relationship of serum alanine aminotransferase (ALT) to body mass index (BMI) in blood donors: the need to correct ALT for BMI in blood donor screening. Jin Kim Y. Jang YH. Arafah MR. Accessed August 4. Warsy AS. Al-Baghli FA.wikipedia. 9. Another point of limitation is that if we have included liver biopsy or the noninvasive markers of liver fibrosis in candidates who were overweight and obese. Kholoud. 2004. 2002. Al-Baghli NA. 2006. Al-Mazrou YY. Al-Maatouq MA. Transfus Med. Oh DK.62:16–20. 5. Factors associated with serum alanine transaminase activity in healthy subjects: consequences for the definition of normal values. et al. Geubel AP. Influence of body mass index. et al. 12.46:2027–2049.31:929–938. 21. 2002. Gretch DR. 15. Khan NB.34:126–133. at http://en. Overweight and obesity in the eastern province of Saudi Arabia. LoK A. 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.Serum ALT levels in a cohort of healthy blood donors and volunteers from Saudi Arabia Authors Queries Journal: Annals of Gastroenterology & Hepatology Paper: agh000002 Title: Serum ALT Levels in a Cohort of Healthy Blood Donors and Volunteers from Saudi Arabia: The Influence of Sex and Body Mass Index Dear Author During the preparation of your manuscript for publication. . Month 2010 Annals of Gastroenterology & Hepatology agh00002 3/9/2010 17:53:34 . in the year 2008) of” for clarity and completeness. Please check if MBI is correct here. 000:(000). Please provide the expansion for ULN. .slm-journals. Please check “p = <001”. Is “range” correct here? Remarks 6 7 8 9 10 11 12 13 14 15 16 www. Please provide the expansion for MBI. Please check if the unit “IU” is OK. Many thanks for your assistance Query Reference 1 2 3 4 5 Query Please check the affiliation. Please check “those with personal or . Please attend to these matters and return this form with your proof.’ has been updated as per reference list. . Please check. Please provide the keywords.”. Please check if the placements of parentheses are correct in the sentence “Serology for hepatitis B virus . Please provide the expansion for CBH. is the insertion “see” OK here? Please check the change in the table numbers (3 and 4) for sequential order. . . The sentence “In addition to . Please check.” is incomplete. the questions listed below have arisen. ‘Prati et al. Please provide the expansion for CHB.com 7 AGH 2010.