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(1) Background: Alanine aminotransferase (ALT) is used to screen for non-alcoholic fatty liver disease (NAFLD) in children; however, the optimal age to commence screening is not determined. Our objective was to describe whether ALT trends from 9-24 years were associated with hepatic steatosis at 24 years in a population-based UK cohort. (2) Methods: The sample included 1156 participants who were assessed for hepatic steatosis at 24 years and had at least two ALT measurements at 9, 15, 17, and/or 24 years. Controlled attenuation parameter scores were used to assess steatosis (low (&lt;248 dB/m), mild/moderate (248-279 dB/m), severe (&gt;279 dB/m)). Sex-stratified mixed-effects models were constructed to assess the liver enzyme trends by steatosis level. (3) Results: The final sample was 41.4% male and 10.4% had severe steatosis. In both sexes, ALT trends from 9 to 24 years differed in those with low vs. severe steatosis at 24 years ( p &lt; 0.001). There was no evidence of differences prior to puberty. At 17 years, the low vs. severe geometric mean ratio (GMR) was 0.69, 95% CI: 0.57-0.85 in males and (0.81, 0.65-1.01) females. At 24 years, the GMR was (0.53, 0.42-0.66) in males and (0.67, 0.54-0.84) females. (4) Conclusions: Higher ALT concentration in adolescence was associated with hepatic steatosis at 24 years. The increased screening of adolescents could strengthen NAFLD prevention and treatment efforts.

ALT Trends through Childhood and Adolescence Associated with Hepatic Steatosis at 24 Years: A Population-Based UK Cohort Study