Can you have fatty liver with a normal LFT?

A routine "LFT" panel usually reports ALT, AST, ALP, GGT, bilirubin, total protein and albumin.

ALT and AST rise when liver cells are actively injured and leak enzymes. Fat and even scarring can be present without ongoing enzyme leakage at the moment the blood is drawn.

Albumin, bilirubin and INR reflect how well the liver is currently functioning, and these often stay normal until disease is advanced.

Reference ranges are also population-based; a value inside the range is not automatically ideal for that individual.

Many people are reassured by a normal LFT and never have their metabolic risk assessed.

Clinicians therefore combine history, examination, metabolic markers, imaging and — where indicated — fibrosis assessment, rather than relying on enzymes alone.

Studies in MASLD cohorts have repeatedly documented significant fibrosis in people with normal ALT, which is why guidelines do not use normal enzymes to exclude disease.

AASLD and EASL–EASD–EASO guidance recommend risk-based fibrosis assessment (for example non-invasive scores such as FIB-4, followed by elastography where appropriate) rather than enzymes alone.