{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,28]],"date-time":"2026-05-28T11:05:05Z","timestamp":1779966305886,"version":"3.53.1"},"reference-count":28,"publisher":"MDPI AG","issue":"11","license":[{"start":{"date-parts":[[2026,5,28]],"date-time":"2026-05-28T00:00:00Z","timestamp":1779926400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background\/Objectives: Metabolic dysfunction-associated steatotic liver disease (MASLD) is getting more prevalent in children with obesity, and simple and non-invasive biomarkers are needed for early detection. In this study, the discriminative performance of the ALT\/AST ratio (AT index) for MASLD was evaluated in comparison with metabolic indices such as HOMA-IR and TyG derivatives. Methods: A total of 410 children with obesity aged 5\u201318 years were included in this prospective, multicenter cross-sectional study. Anthropometric measurements, laboratory data, and abdominal ultrasonography findings of the participants were evaluated. MASLD was diagnosed based on ultrasonographic findings. The discriminative performance of the indices was evaluated using ROC analysis, and factors independently associated with MASLD were assessed using multivariate logistic regression analysis. Results: BMI SDS, ALT, AT index, insulin, HOMA-IR, and TyG\/ALT values were found to be significantly higher in the MASLD (+) group (p &lt; 0.05). The AT index demonstrated statistically significant but modest discriminative ability for MASLD (AUC = 0.621; p &lt; 0.001) and showed 70.5% sensitivity and 50.7% specificity at a cutoff value of &gt;0.88. In the multivariate analysis, the AT index (OR: 3.401; 95% CI: 1.717\u20136.735; p &lt; 0.001) and BMI SDS were identified as factors independently associated with MASLD.HOMA-IR and prolactin-related indices were not found to be significant as independent predictors. Conclusions: The ALT\/AST ratio is a simple and accessible biomarker associated with MASLD in children with obesity. Although its discriminative performance is modest, its association with hepatic involvement and metabolic dysfunction suggests that it may provide supportive exploratory information in the evaluation of MASLD. However, further validation studies are required before broader clinical application.<\/jats:p>","DOI":"10.3390\/jcm15114160","type":"journal-article","created":{"date-parts":[[2026,5,28]],"date-time":"2026-05-28T09:57:43Z","timestamp":1779962263000},"page":"4160","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["The ALT\/AST Ratio as a Predictor of MASLD in Obese Children: A Comparative Analysis with Metabolic Indices Including HOMA-IR and TyG"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6869-9397","authenticated-orcid":false,"given":"Hilmi Onur","family":"Kabuk\u00e7u","sequence":"first","affiliation":[{"name":"Department of Pediatrics, Private Kastamonu Anatolia Hospital, 37200 Kastamonu, Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"\u0130lhan","family":"Hazer","sequence":"additional","affiliation":[{"name":"Department of Pediatric Endocrinology, K\u00fctahya Health Sciences University, 43100 Kutahya, Turkey"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,5,28]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"e186422","DOI":"10.1172\/JCI186422","article-title":"MASLD in children: Integrating epidemiologic trends with mechanistic and translational advances","volume":"135","author":"Schwimmer","year":"2025","journal-title":"J. Clin. Investig."},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN), European Association for the Study of the Liver (EASL), North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN), Latin-American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (LASPGHAN), Asian Pan-Pacific Society for Pediatric Gastroenterology, Hepatology and Nutrition (APPSPGHAN), Pan Arab Society for Pediatric Gastroenterology and Nutrition (PASPGHAN), Commonwealth Association of Paediatric Gastroenterology & Nutrition (CAPGAN), and Federation of International Societies of Pediatric Hepatology, Gastroenterology and Nutrition (FISPGHAN) (2024). Pediatric fatty liver disease has unique characteristics: A joint statement supporting the new nomenclature. JPGN Rep., 5, 1190\u20131196.","DOI":"10.1002\/jpn3.12156"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"569","DOI":"10.1007\/s12519-024-00814-1","article-title":"Prevalence of nonalcoholic fatty liver disease in children and adolescents: A systematic review and meta-analysis","volume":"20","author":"Lee","year":"2024","journal-title":"World J. Pediatr."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"101419","DOI":"10.1016\/j.jhepr.2025.101419","article-title":"Defining pediatric MASLD using insulin resistance indices","volume":"7","author":"Song","year":"2025","journal-title":"JHEP Rep."},{"key":"ref_5","first-page":"e70137","article-title":"Consensus statement on metabolic dysfunction-associated steatotic liver disease in children and adolescents from the joint TASL-TSPGHAN expert committee","volume":"8","author":"Lin","year":"2024","journal-title":"JGH Open"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"e38241","DOI":"10.1097\/MD.0000000000038241","article-title":"Triglyceride\u2013glucose\u2013alanine aminotransferase index: A noninvasive serum predictor for identifying the severity of pediatric nonalcoholic fatty liver disease","volume":"103","author":"Noh","year":"2024","journal-title":"Medicine"},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Song, K., Lee, H.W., Choi, H.S., Park, G., Lee, H.S., Kim, S.J., Lee, M., Suh, J., Kwon, A., and Kim, H.-S. (2022). Comparison of the modified TyG indices and other parameters to predict non-alcoholic fatty liver disease in youth. Biology, 11.","DOI":"10.3390\/biology11050685"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"319","DOI":"10.1097\/MPG.0000000000001482","article-title":"NASPGHAN Clinical Practice Guideline for the Diagnosis and Treatment of Nonalcoholic Fatty Liver Disease in Children: Recommendations from the Expert Committee on NAFLD (ECON) and the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN)","volume":"64","author":"Vos","year":"2017","journal-title":"J. Pediatr. Gastroenterol. Nutr."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"251","DOI":"10.1055\/a-2043-1044","article-title":"Prolactin is a key factor for nonalcoholic fatty liver disease in obese children","volume":"55","author":"Zhang","year":"2023","journal-title":"Horm. Metab. Res."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"243","DOI":"10.1007\/s00431-023-05296-3","article-title":"Predictive markers of metabolically healthy obesity in children and adolescents: Can the AST\/ALT ratio be used as a simple and reliable diagnostic indicator?","volume":"183","author":"Celik","year":"2024","journal-title":"Eur. J. Pediatr."},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Xuan, Y., Wu, D., Zhang, Q., Yu, Z., Yu, J., and Zhou, D. (2024). Elevated ALT\/AST ratio as a marker for NAFLD risk and severity: Findings from a cross-sectional analysis in the United States. Front. Endocrinol., 15.","DOI":"10.3389\/fendo.2024.1457598"},{"key":"ref_12","unstructured":"WHO Multicentre Growth Reference Study Group (2006). WHO Child Growth Standards: Length\/Height-for-Age, Weight-for-Age, Weight-for-Length, Weight-for-Height and Body Mass Index-for-Age: Methods and Development, WHO Press."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"e151","DOI":"10.2337\/dci23-0036","article-title":"Guidelines and Recommendations for Laboratory Analysis in the Diagnosis and Management of Diabetes Mellitus","volume":"46","author":"Sacks","year":"2023","journal-title":"Diabetes Care"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"412","DOI":"10.1007\/BF00280883","article-title":"Homeostasis model assessment: Insulin resistance and \u03b2-cell function from fasting plasma glucose and insulin concentrations in man","volume":"28","author":"Matthews","year":"1985","journal-title":"Diabetologia"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"299","DOI":"10.1089\/met.2008.0034","article-title":"The product of fasting glucose and triglycerides as an indicator of insulin resistance in apparently healthy subjects","volume":"6","year":"2008","journal-title":"Metab. Syndr. Relat. Disord."},{"key":"ref_16","unstructured":"European Association for the Study of the Liver (2025). EASL clinical practice guidelines on the management of hepatocellular carcinoma. J. Hepatol., 82, 315\u2013374."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"546","DOI":"10.3345\/cep.2025.00157","article-title":"Metabolic dysfunction-associated steatotic liver disease in children: A practical update based on Indian Society of Pediatric Gastroenterology, Hepatology and Nutrition (ISPGHAN) 2024 guidelines","volume":"68","author":"Agrawal","year":"2025","journal-title":"Clin. Exp. Pediatr."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"179","DOI":"10.1002\/ajum.12381","article-title":"Hepatic steatosis: Qualitative and quantitative sonographic assessment in comparison to histology","volume":"27","author":"Tan","year":"2024","journal-title":"Australas. J. Ultrasound Med."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"230","DOI":"10.1016\/j.jss.2025.10.053","article-title":"A Structured Guide to Univariate Test Selection Based on Normality, Variance Homogeneity, and Graphical Data Exploration","volume":"318","year":"2026","journal-title":"J. Surg. Res."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"e078378","DOI":"10.1136\/bmj-2023-078378","article-title":"TRIPOD+AI Statement: Updated Guidance for Reporting Clinical Prediction Models That Use Regression or Machine Learning Methods","volume":"385","author":"Collins","year":"2024","journal-title":"BMJ"},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Arredondo Montero, J. (2026). Clinical Prediction Models: From Foundational Concepts to Practical Application. Diagnosis, Online ahead of print.","DOI":"10.1515\/dx-2025-0152"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"882","DOI":"10.1093\/aje\/kwh101","article-title":"Limitations of the Odds Ratio in Gauging the Performance of a Diagnostic, Prognostic, or Screening Marker","volume":"159","author":"Pepe","year":"2004","journal-title":"Am. J. Epidemiol."},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Amernia, B., Moosavy, S.H., Banookh, F., and Zoghi, G. (2021). FIB-4, APRI, and AST\/ALT ratio compared to FibroScan for the assessment of hepatic fibrosis in patients with non-alcoholic fatty liver disease in Bandar Abbas, Iran. BMC Gastroenterol., 21.","DOI":"10.1186\/s12876-021-02038-3"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"328","DOI":"10.1002\/hep.29367","article-title":"The diagnosis and management of nonalcoholic fatty liver disease: Practice guidance from the American Association for the Study of Liver Diseases","volume":"67","author":"Chalasani","year":"2018","journal-title":"Hepatology"},{"key":"ref_25","first-page":"306","article-title":"Triglyceride Glucose Index is Associated with Ultrasonographic Fatty Liver Indicator in Children and Adolescents with Non-Alcoholic Fatty Liver Disease","volume":"16","author":"Kim","year":"2024","journal-title":"J. Clin. Res. Pediatr. Endocrinol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"208","DOI":"10.1186\/s12944-024-02144-7","article-title":"Evaluation of the Ability of Insulin Resistance and Lipid-Related Indices to Predict the Presence of NAFLD in Obese Adolescents","volume":"23","author":"Yetim","year":"2024","journal-title":"Lipids Health Dis."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1164","DOI":"10.1016\/j.jhep.2026.02.016","article-title":"Update in Clinical Science: MASLD in Children and Adolescents","volume":"84","author":"Lefere","year":"2026","journal-title":"J. Hepatol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1974","DOI":"10.2337\/dc12-1893","article-title":"Circulating prolactin associates with diabetes and impaired glucose regulation: A population-based study","volume":"36","author":"Wang","year":"2013","journal-title":"Diabetes Care"}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/11\/4160\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,28]],"date-time":"2026-05-28T10:22:12Z","timestamp":1779963732000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/11\/4160"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,28]]},"references-count":28,"journal-issue":{"issue":"11","published-online":{"date-parts":[[2026,6]]}},"alternative-id":["jcm15114160"],"URL":"https:\/\/doi.org\/10.3390\/jcm15114160","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,28]]}}}