Analysis of the De Ritis ratio in different diseases: an observation in a tertiary care hospital
DOI:
https://doi.org/10.18203/2320-6012.ijrms20252789Keywords:
De Ritis ratio, Liver function test, Systemic diseases, Prognostic marker, Tertiary care hospital, Cross-sectional studyAbstract
Background: One useful biomarker for hepatic and extra-hepatic disorders is the De Ritis ratio of serum aspartate aminotransferase/ alanine aminotransferase (AST/ALT). There is growing evidence that it affects the prognosis of diseases related to the heart, metabolism, nervous system, and kidneys. In a tertiary care context, this study sought to assess its variation among age groups and systemic disorders.
Methods: Over the course of two months in 2025, a cross-sectional study was carried out at Peerless Hospital in Kolkata. There were 25 controls and 344 cases. Clinical diagnosis was used to categorize participants into groups related to gastrointestinal, cardiovascular, metabolic, neurological, kidney, and gynaecological conditions. The De Ritis ratio was computed and AST and ALT levels were tested. Data were stratified by age and analysed using Pearson correlation.
Results: The De Ritis ratio was elevated in all disease groups compared to controls. Cardiovascular patients aged between 31-60 years had the highest ratios. Metabolic, gastrointestinal, and neurological disorders showed progressive increases with age. Kidney disease (KD) patients had the highest ratios in elderly groups. Strong positive correlations were observed between gastrointestinal and neurological (r=0.95, p<0.00001), and between metabolic and neurological groups (r=0.75, p=0.0047). A strong negative correlation existed between cardiovascular and metabolic groups (r=-0.76, p=0.0044).
Conclusions: The De Ritis ratio's wide range of applications beyond hepatology is supported by the notable variance it exhibits with age and disease type. Our study demonstrates that it could be a helpful prognostic marker for a variety of systemic diseases.
Metrics
References
Botros M, Sikaris KA. The De Ritis ratio: the test of time. Clin Biochem Rev. 2013;34(3):117-30.
Ndrepepa G, Cassese S, Scalamogna M, Lahu S, Aytekin A, Xhepa E, et al. Association of De Ritis ratio with prognosis in patients with coronary artery disease and aminotransferase activity within and outside the healthy values of reference range. J Clin Med. 2023;12(9):3174. DOI: https://doi.org/10.3390/jcm12093174
Ndrepepa G. De Ritis ratio and cardiovascular disease: evidence and underlying mechanisms. J Lab Precis Med. 2023;8:6. DOI: https://doi.org/10.21037/jlpm-22-68
Giannini EG, Testa R, Savarino V. Liver enzyme alteration: a guide for clinicians. CMAJ. 2005;172(3):367-79. DOI: https://doi.org/10.1503/cmaj.1040752
Kwo PY, Cohen SM, Lim JK. ACG clinical guideline: evaluation of abnormal liver chemistries. Am J Gastroenterol. 2017;112:18-35. DOI: https://doi.org/10.1038/ajg.2016.517
Pettersson J, Hindorf U, Persson P, Bengtsson T, Malmqvist U, Werkstrom V, et al. Muscular exercise can cause highly pathological liver function tests in healthy men. Br J Clin Pharmacol. 2007;65(2):253-9. DOI: https://doi.org/10.1111/j.1365-2125.2007.03001.x
Oh RC, Hustead TR. Causes and evaluation of mildly elevated liver transaminase levels. Am Fam Physician. 2011;84(9):1003-8.
Lopes EP, Sette LH, Sette JB, Oliveira RA. AST/ALT ratio in hepatocellular carcinoma patients: can it be used as a prognostic factor? Int Arch Med. 2012;5:20.
Yokoyama M, Watanabe T, Otaki Y, Takahashi H, Arimoto T, Shishido T, et al. Association of the aspartate aminotransferase to alanine aminotransferase ratio with BNP level and cardiovascular mortality in the general population: the Yamagata study 10-year follow-up. Dis Markers. 2016;2016:9. DOI: https://doi.org/10.1155/2016/4857917
Steininger M, Winter MP, Reiberger T, Koller L, El-Hamid F, Forster S, et al. De-Ritis ratio improves long-term risk prediction after acute myocardial infarction. J Clin Med. 2018;7:474. DOI: https://doi.org/10.3390/jcm7120474
Djakpo DK, Wang ZQ, Shrestha M. The significance of transaminase ratio (AST/ALT) in acute myocardial infarction. Arch Med Sci Atheroscler Dis. 2020;5:e279-83. DOI: https://doi.org/10.5114/amsad.2020.103028
Nimkar S, Varma A, Acharya S, Kumar S, Wanjari AK, Bawankule S. A study protocol for estimating the association of De Ritis ratio (AST/ALT) with outcomes in patients of acute ischemic stroke. J Pharm Res Int. 2021;33:186-93. DOI: https://doi.org/10.9734/jpri/2021/v33i64A35318
Ahmadabad MA, Naeimi A, Keymoradzadeh A, Faghani S, Ahmadabad MA, Boroujeni NA, et al. Evaluation of De Ritis (AST/ALT), ALP/ALT, and AST/ALP ratios as prognostic factors in patients with acute ischemic stroke. BMC Neurol. 2022;22:450. DOI: https://doi.org/10.1186/s12883-022-02989-4
Li Q, Lan W. Association between De-Ritis ratio (AST/ALT) and mortality in patients with chronic kidney disease: a retrospective cohort study. Sci Rep. 2025;15(1):9649. DOI: https://doi.org/10.1038/s41598-025-93184-1
Sette LH, de Almeida Lopes EP. Liver enzymes serum levels in patients with chronic kidney disease on hemodialysis: a comprehensive review. Clinics. 2014;69(4):271-8. DOI: https://doi.org/10.6061/clinics/2014(04)09
Wang X, Li H, Ji L, Cang J, Zhao H. Association between aspartate aminotransferase to alanine aminotransferase ratio and the risk of diabetes in Chinese prediabetic population: a retrospective cohort study. Front Public Health. 2023;10:2022. DOI: https://doi.org/10.3389/fpubh.2022.1045141
Niu H, Zhou Y. Nonlinear relationship between AST-to-ALT ratio and the incidence of type 2 diabetes mellitus: a follow-up study. Int J Gen Med. 2021;14:8373-82. DOI: https://doi.org/10.2147/IJGM.S341790
Sookoian S, Pirola CJ. Alanine and aspartate aminotransferase and glutamine-cycling pathway: their roles in pathogenesis of metabolic syndrome. World J Gastroenterol. 2012;18(29):3775-81. DOI: https://doi.org/10.3748/wjg.v18.i29.3775
Lai X, Chen H, Dong X, Zhou G, Liang D, Xu F, et al. AST to ALT ratio as a prospective risk predictor for liver cirrhosis in patients with chronic HBV infection. Eur J Gastroenterol Hepatol. 2024;36(3):338-44. DOI: https://doi.org/10.1097/MEG.0000000000002708
Li J, Cao D, Peng L, Meng C, Xia Z, Li Y, et. al. Potential clinical value of pretreatment De Ritis ratio as a prognostic biomarker for renal cell carcinoma. Front Oncol. 2021;11:780906. DOI: https://doi.org/10.3389/fonc.2021.780906
Han SW, Lee SH, Kim JH, Lee JJ, Park YH, Kim S, et al. Association of serum liver enzymes with brain amyloidopathy and cognitive performance. J Alzheimers Dis. 2023;7(1):1465-74. DOI: https://doi.org/10.3233/ADR-230148
Li R, Zhu WJ, Wang F, Tang X, Luo F. AST/ALT ratio as a predictor of mortality and exacerbations of PM/DM-ILD in 1 year – a retrospective cohort study with 522 cases. Arthritis Res Ther. 2020;22(1):202. DOI: https://doi.org/10.1186/s13075-020-02286-w
Wu C, Wang Q, Zhou CY, Sun HX, Lin YS, Jiao XF, et al. Association of AST/ALT (De Ritis) ratio with sarcopenia in a Chinese population of community-dwelling elderly. Heliyon. 2023;9(10):e20427. DOI: https://doi.org/10.1016/j.heliyon.2023.e20427
Woreta TA, Alqahtani SA. Evaluation of abnormal liver tests. Med Clin North Am. 2014;98(1):1-16. DOI: https://doi.org/10.1016/j.mcna.2013.09.005
Nayak AM, Sahana PK. De Ritis ratio (AST/ALT) as an important prognostic marker in COVID-19. Int J Res Med Sci. 2020;8:3951-5.