turner s syndrome ( ts ) was first detected by ullrich in an 8-year - old german girl and then described by henry turner in 1938 [ 1 , 2 ] . ts is the most common sex chromosome abnormality in female gender and occurs approximately in 50 per 100,000 live births [ 3 , 4 ] . ts is defined by a complete or partial ( includes the tip of its short arm ) omission of one x chromosome in females [ 5 , 6 ] . abnormalities in glucose metabolism , lipid metabolism , liver enzymes , and thyroid function tests have been reported in patients with ts and should be checked out at 2-year intervals [ 8 - 13 ] . elevation of liver enzymes was reported in adults with a fivefold increase in the risk of cirrhosis [ 14 - 16 ] . liver enzymes abnormalities have been suggested to have relationships with hormone therapy , autoimmunity or obesity [ 17 , 18 ] . ts patients are predisposed to obesity [ 4 , 19 ] , partly because of low physical fitness and a sedentary lifestyle [ 14 , 20 ] . therefore , the objective of this study was to assess relationship between obesity and liver enzymes level in ts patients . all 41 karyotype - proven participants of this cross - sectional study were selected from ts patients who were referred to the endocrinology and metabolism research center of iran university of medical sciences . after taking detailed history about hepatic disease symptoms , cigarette smoking , alcohol drinking , and drug history , the patients with known hepatic disease and/or history of taking medications with hepatotoxic effects were excluded . demographic profiles including age , weight , height and body mass index ( bmi = weight ( kg)/height ( m ) ) were gathered . the heights of all patients were measured by harpenter stadiometer and for measuring their weight , we used a digital scale . the subjects were divided into two groups including overweight ( patients with bmi > 85th percentile for sex and age ) and normal weight ( patients with bmi < 85th percentile for sex and age ) . a 1.5 ml venous fasting blood sample was taken and kept in the sterile edta containing test tubes at -70 c . all samples were transferred to laboratory of endocrine research center for measuring serum concentration of liver enzymes , including aspartate transaminase ( ast ) , alanine transaminase ( alt ) and alkaline phosphatase ( alkph ) . iu / l for ast , alt and alkph , respectively [ 21 , 22 ] . in patients with elevated liver enzymes , the tests were done for the second time . for subjects that the second test confirmed elevated levels of liver enzymes , liver ultrasonography , serologic test for viral hepatitis ( hbsag , anti - hcv antibody ) , autoantibodies ( anti - smooth muscle antibody ( anti - sma ) , anti - nuclear antibody ( ana ) , and anti - liver - kidney microsome ( lkm ) antibody ) , 1-antitrypsin , anti - endomysial antibody , triglyceride , cholesterol , glucose , urine copper and urine ceruloplasmin were done . this study was approved by the ethics committee of endocrine research center ( firuzgar ) . the data were analyzed using spss software version 13.0 for windows ( spss inc . , comparison of liver enzyme values between normal and overweight patients was performed using the independent t - test . the p - values less than 0.05 were considered significant and a power of 80% was considered in the analysis . also for multivariable analysis , linear regression was performed between liver enzymes and bmi , age , age of diagnosis weight and height . all 41 karyotype - proven participants of this cross - sectional study were selected from ts patients who were referred to the endocrinology and metabolism research center of iran university of medical sciences . after taking detailed history about hepatic disease symptoms , cigarette smoking , alcohol drinking , and drug history , the patients with known hepatic disease and/or history of taking medications with hepatotoxic effects were excluded . demographic profiles including age , weight , height and body mass index ( bmi = weight ( kg)/height ( m ) ) were gathered . the heights of all patients were measured by harpenter stadiometer and for measuring their weight , we used a digital scale . the subjects were divided into two groups including overweight ( patients with bmi > 85th percentile for sex and age ) and normal weight ( patients with bmi < 85th percentile for sex and age ) . a 1.5 ml venous fasting blood sample was taken and kept in the sterile edta containing test tubes at -70 c . all samples were transferred to laboratory of endocrine research center for measuring serum concentration of liver enzymes , including aspartate transaminase ( ast ) , alanine transaminase ( alt ) and alkaline phosphatase ( alkph ) . iu / l for ast , alt and alkph , respectively [ 21 , 22 ] . in patients with elevated liver enzymes , the tests were done for the second time . for subjects that the second test confirmed elevated levels of liver enzymes , liver ultrasonography , serologic test for viral hepatitis ( hbsag , anti - hcv antibody ) , autoantibodies ( anti - smooth muscle antibody ( anti - sma ) , anti - nuclear antibody ( ana ) , and anti - liver - kidney microsome ( lkm ) antibody ) , 1-antitrypsin , anti - endomysial antibody , triglyceride , cholesterol , glucose , this study was approved by the ethics committee of endocrine research center ( firuzgar ) . the data were analyzed using spss software version 13.0 for windows ( spss inc . , comparison of liver enzyme values between normal and overweight patients was performed using the independent t - test . the p - values less than 0.05 were considered significant and a power of 80% was considered in the analysis . , linear regression was performed between liver enzymes and bmi , age , age of diagnosis weight and height . mean (  sd ) age , height and weight were 16.69  6.86 years , 129.21  24.16 cm and 37.73  13.94 kg , respectively . mean (  sd ) age at the time of diagnosis was 12.09  6.44 years . data are presented as mean  sd . mean (  sd ) bmi was 21.20  4.05 distribution of bmi is shown in figure 1 . according to age and sex - matched standard bmi curve , the patients were divided into two groups as control group including 27 subjects ( 65.8% ) with normal bmi ( i.e. , bmi < 85th percentile ) and case group including 14 subjects ( 34.2% ) who were overweight ( bmi > 85th percentile ) . of those , 28 cases ( 68.2% ) had monosomic pattern ( 45xo ) according to their karyotype while others karyotypes were mosaicism or isochromosome ( 45xo/46xx in six subjects ( 13.6% ) , 45xo/46xy in three subjects ( 6.6% ) , 46xi(x ) ( q10 ) in three subjects ( 6.6% ) , and 45xo/44 in one patient ( 2.2% ) ) . one of them had extrahepatic biliary atresia and after therapeutic surgery , the enzymes level returned to the normal range . another patient was a 14-year - old girl with a height of 136.5 cm and a weight of 49 kg . the enzyme elevation showed a progressive pattern over 8 months ( ast = 77 u / l139 u / l and alt = 126 u / l201 the patient s bmi in the time of liver enzyme elevation was 26.3 which increased to 28.4 when the enzymes level returned to normal range . distribution of bmi in study population .   the two above mentioned patients were excluded . mean (  sd ) liver enzyme levels in overweight patients were ast = 27  5.4 u / l , alt = 20.1  4.9 u / l , and alkph = 583.4  269 u / l . in those with normal bmi , the figures were ast = 29.6 11.7 u / l , alt = 22.2  11.7 u / l , and alkph = 472.8  323 u / l . there were no significant differences between patients with normal bmi and those who were overweight regarding serum liver enzymes levels . p values were 0.34 for ast , 0.52 for alt and 0.28 for alkph . in linear regression model for ast , alt and alkph with age , bmi , height , weight and age of diagnosis , the significance for all variables were higher than 0.05 except for age at the time of diagnosis and serum level of alkph ( sig . = 0.002 ) . on the other hand , our multivariable analysis showed that in the relationship of other variables , the age of diagnoses was the only variable that was associated with higher level of alkph . the bmi and weight had not significant association with liver enzymes ( for ast , p = 0.521 and 0.492 ; alt , p = 0.955 and 0.659 and alkph , p = 0.964 and 0.697 , respectively ) . our study about association of obesity and liver enzymes level in ts showed no significant relation between obesity and serum liver enzymes level . ts actually is a multi - organ disease and the affected patients have various complications as the result of their illness and need very exact follow - up and good management . one of the organs which might be involved is the liver . in our ts patients , one case had extrahepatic biliary atresia ( a rare condition ) , and one overweight patient ( bmi = 26.3 ) had steatohepatitis . the causes suggested for liver enzymes abnormalities in ts include hormone therapy and autoimmunity [ 17 , 18 , 23 ] . obesity , which is a characteristic feature of girls with ts , is discussed as one of the causes of liver involvement [ 24 - 27 ] in ts which could be presented by elevated liver enzyme levels . based on our study , no relationship was seen between obesity and liver enzyme levels . this finding is in accordance with earlier studies in this field [ 17 , 28 , 29 ] . seventy - nine ( 36% ) of their patients showed elevated levels in one or more liver enzymes at start , and another 23% of patients had developed elevated liver enzymes during a 5-year follow - up . in their study , the patients who had enzymes elevation had higher bmi , triglyceride , cholesterol level compared to those with normal liver enzymes level . but only the total cholesterol level could play as a significant predictor for liver enzymes elevation . in their study , elevated liver enzymes were more common in patients with age between 26 and 45 years old . our study showed low frequency of abnormal liver function in young ts patients which is in contrast to the high incidence of liver function abnormality in adult ts patients ( like el - mansoury et al s study ) , suggesting that long - term hormone therapy or worsening or long - term obesity may be related to the development of abnormal liver function in some ts patients . in another study , larizza et al followed two groups of turner s patients , 22 patients with raised liver enzymes ( group a ) and 48 patients with normal enzymes level ( group b ) for a period of 0.8 - 21.9 years . they found hepatitis c and autoimmunity as the causes of liver enzyme elevation in some cases of group a patients . weight excess standard deviation scores ( sds ) were significantly higher in turner patients with liver enzyme elevation . so authors concluded , although an autoimmune pathogenesis might be considered in some cases , weight excess seems the most frequent cause of increased liver enzymes in ts . in wasniewska et al s study of 214 ts patients younger than 20 years , only 19 ( 8.9% ) had elevated liver enzymes in 2 years follow - up . according to results of this study , authors concluded that both obesity and autoimmunity are not frequently involved in the etiology of ts liver abnormality . salerno et al monitored liver enzymes level in 70 patients with ts for a mean period of 7.6  4.2 years . they observed increased liver enzyme in 14 out of 70 patients ( 20% ) . in the majority of cases ( 10/14 ) , it was drug - related , in two cases it was autoimmunity - related , and in one case it was cryptogenic . although obesity was a frequent finding , it was considered the cause of liver abnormality only in one patient . the small sample size could be as a limitation in our study , so we suggest a larger cohort study for determining the exact role of obesity in the changes of liver enzymes level in ts patients . there was no statistically significant difference regarding liver enzyme levels ( ast , alt , and alkph ) between normal bmi and overweight ts teenagers . in other words , obesity may not be a cause for difference in terms of serum liver enzyme levels abnormalities . there was no statistically significant difference regarding liver enzyme levels ( ast , alt , and alkph ) between normal bmi and overweight ts teenagers . in other words , obesity may not be a cause for difference in terms of serum liver enzyme levels abnormalities . this work was also supported by grant no . 202 from endocrinology and metabolism research center affiliated to iums .
backgroundliver enzyme abnormalities have been reported in turner s syndrome ( ts ) . 
 there are some studies about possible causes of abnormal levels of liver enzymes . 
 one of the main suggestions is obesity . 
 the study aimed to determine the relationship between obesity and liver enzymes levels in patients with ts.methodsforty-one karyotype - proven ts patients referred to endocrinology and metabolism research center were included in this cross - sectional study . 
 height and weight of patients were measured and their body mass index ( bmi ) was calculated . 
 the patients were divided into two groups as the control group including 27 cases ( 65.8% ) with normal bmi ( defined as < 85th percentile for age and gender ) , and the overweight group including 14 cases ( 34.2% ) ( defined as bmi > 85th percentile for age and gender ) . 
 serum levels of aspartate transaminase ( ast ) , alanine transaminase ( alt ) and alkaline phosphatase ( alkph ) were measured.resultsthere were no statistically significant differences regarding ast ( 27  2.7 vs. 29.6  5.85 u / l ; p = 0.3 ) , alt ( 20.1  2.45 vs. 22.2  5.85 u / l ; p = 0.5 ) , and alkph ( 583.4  2.45 vs. 472.8  161.5 u / l ; p = 0.28 ) between overweight ts patients and those with normal bmi.conclusionthere was no significant difference in liver enzyme levels between ts patients with normal bmi and those who were overweight .