LAUSR

T o the Editor: I read with interest the recent practice guideline concerning the evaluation of nonalcoholic fatty liver disease in children, which is often discovered on the basis of elevated transaminases (1). This was an excellent review. I, however, believe that there was an important omission. In the list of recommended additional testing, testing for creatine kinase (CK) is not mentioned. Children with muscle diseases, particularly the dystrophinopathies, may first come to attention because of elevated transaminases. Transaminases are expressed in both liver and skeletal muscles; CK and transaminase levels rise in a relatively linear relationship amongst boys with Duchenne and Becker Muscular Dystrophy (2). It is thus extremely important that the evaluation of elevated transaminases include a neuromotor examination and a CK. This relatively inexpensive test can save a patient from further hepatologic testing and identify their muscle disease earlier (3). I recommend that routine CK testing be added to the fine algorithm illustrated in this article.