The entire spectrum of NAFLD severity has been shown to exist in patients with normal liver enzymes; multiple studies have observed no difference in disease severity between this group and those with abnormal liver enzymes.33–35 Interestingly, if more conservative thresholds are utilised in our population at the 19/30 U/L cut-off, as advocated by the work of Prati et al,20 then a normal ALT is still observed in 42% of individuals with elevated liver stiffness and in 18% of those with cirrhosis. This evidence concerns the gene GPT and metabolic dysfunction-associated steatotic liver disease.