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Conte C, Cipponeri E, Roden M. Diabetes Mellitus, Energy Metabolism, and COVID-19. Endocr Rev 2024; 45:281-308. [PMID: 37934800 PMCID: PMC10911957 DOI: 10.1210/endrev/bnad032] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 08/30/2023] [Accepted: 11/01/2023] [Indexed: 11/09/2023]
Abstract
Obesity, diabetes mellitus (mostly type 2), and COVID-19 show mutual interactions because they are not only risk factors for both acute and chronic COVID-19 manifestations, but also because COVID-19 alters energy metabolism. Such metabolic alterations can lead to dysglycemia and long-lasting effects. Thus, the COVID-19 pandemic has the potential for a further rise of the diabetes pandemic. This review outlines how preexisting metabolic alterations spanning from excess visceral adipose tissue to hyperglycemia and overt diabetes may exacerbate COVID-19 severity. We also summarize the different effects of SARS-CoV-2 infection on the key organs and tissues orchestrating energy metabolism, including adipose tissue, liver, skeletal muscle, and pancreas. Last, we provide an integrative view of the metabolic derangements that occur during COVID-19. Altogether, this review allows for better understanding of the metabolic derangements occurring when a fire starts from a small flame, and thereby help reducing the impact of the COVID-19 pandemic.
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Affiliation(s)
- Caterina Conte
- Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Roma Open University, Rome 00166, Italy
- Department of Endocrinology, Nutrition and Metabolic Diseases, IRCCS MultiMedica, Milan 20099, Italy
| | - Elisa Cipponeri
- Department of Endocrinology, Nutrition and Metabolic Diseases, IRCCS MultiMedica, Milan 20099, Italy
| | - Michael Roden
- Department of Endocrinology and Diabetology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf 40225, Germany
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich-Heine-University Düsseldorf, Düsseldorf 40225, Germany
- German Center for Diabetes Research, Partner Düsseldorf, Neuherberg 85764, Germany
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2
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Quarleri J, Delpino MV. Molecular mechanisms underlying SARS-CoV-2 hepatotropism and liver damage. World J Hepatol 2024; 16:1-11. [PMID: 38313242 PMCID: PMC10835487 DOI: 10.4254/wjh.v16.i1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/04/2023] [Accepted: 12/28/2023] [Indexed: 01/23/2024] Open
Abstract
In coronavirus disease 2019 (COVID-19), severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) primarily targets the respiratory system, but evidence suggests extrapulmonary organ involvement, notably in the liver. Viral RNA has been detected in hepatic tissues, and in situ hybridization revealed virions in blood vessels and endothelial cells. Electron microscopy confirmed viral particles in hepatocytes, emphasizing the need for understanding hepatotropism and direct cytopathic effects in COVID-19-related liver injury. Various factors contribute to liver injury, including direct cytotoxicity, vascular changes, inflammatory responses, immune reactions from COVID-19 and vaccinations, and drug-induced liver injury. Although a typical hepatitis presentation is not widely documented, elevated liver biochemical markers are common in hospitalized COVID-19 patients, primarily showing a hepatocellular pattern of elevation. Long-term studies suggest progressive cholestasis may affect 20% of patients with chronic liver disease post-SARS-CoV-2 infection. The molecular mechanisms underlying SARS-CoV-2 infection in the liver and the resulting liver damage are complex. This "Editorial" highlights the expression of the Angiotensin-converting enzyme-2 receptor in liver cells, the role of inflammatory responses, the impact of hypoxia, the involvement of the liver's vascular system, the infection of bile duct epithelial cells, the activation of hepatic stellate cells, and the contribution of monocyte-derived macrophages. It also mentions that pre-existing liver conditions can worsen the outcomes of COVID-19. Understanding the interaction of SARS-CoV-2 with the liver is still evolving, and further research is required.
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Affiliation(s)
- Jorge Quarleri
- Instituto de Investigaciones Biomédicas en Retrovirus y Sida (INBIRS), Universidad de Buenos Aires (UBA), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires 1121, Argentina.
| | - M Victoria Delpino
- Instituto de Investigaciones Biomédicas en Retrovirus y Sida (INBIRS), Universidad de Buenos Aires (UBA), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires 1121, Argentina
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3
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Pepe-Mooney BJ, Smith CJ, Sherman MS, North TE, Padera RF, Goessling W. SARS-CoV-2 viral liver aggregates and scarce parenchymal infection implicate systemic disease as a driver of abnormal liver function. Hepatol Commun 2023; 7:e0290. [PMID: 37889528 PMCID: PMC10615432 DOI: 10.1097/hc9.0000000000000290] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 08/22/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND Liver function tests (LFTs) are elevated in >50% of hospitalized individuals infected with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), with increased enzyme levels correlating with a more severe COVID-19 course. Despite these observations, evaluations of viral presence within liver parenchyma and viral impact on liver function remain controversial. METHODS AND RESULTS Our work is a comprehensive immunopathological evaluation of liver tissue from 33 patients with severe, and ultimately fatal, cases of SARS-CoV-2 infection. Coupled with clinical data, we reveal the absence of SARS-CoV-2 infection in cholangiocytes and hepatocytes despite dramatic systemic viral presence. Critically, we identify significant focal viral sinusoidal aggregates in 2/33 patients and single viral RNA molecules circulating in the hepatic sinusoids of 15/33 patients. Utilizing co-immunofluorescence, focal viral liver aggregates in patients with COVID-19 were colocalized to platelet and fibrin clots, indicating the presence of virus-containing sinusoidal microthrombi. Furthermore, this patient cohort, from the initial months of the COVID-19 pandemic, demonstrates a general downtrend of LFTs over the course of the study timeline and serves as a remarkable historical time point of unattenuated viral replication within patients. CONCLUSIONS Together, our findings indicate that elevated LFTs found in our patient cohort are not due to direct viral parenchymal infection with SARS-CoV-2 but rather likely a consequence of systemic complications of COVID-19. This work aids in the clinical treatment considerations of patients with SARS-CoV-2 as therapies for these patients may be considered in terms of their direct drug hepatotoxity rather than worsening hepatic function due to direct infection.
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Affiliation(s)
- Brian J. Pepe-Mooney
- Genetics Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Harvard–MIT Division of Health Sciences and Technology, Cambridge, Massachusetts, USA
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Colton J. Smith
- Genetics Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marc S. Sherman
- Genetics Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Trista E. North
- Stem Cell Program, Division of Hematology/Oncology, Boston Children’s Hospital, Boston, Massachusetts, USA
- Developmental and Regenerative Biology Program, Harvard Medical School, Boston, Massachusetts, USA
- Harvard Stem Cell Institute, Cambridge, Massachusetts, USA
| | - Robert F. Padera
- Harvard–MIT Division of Health Sciences and Technology, Cambridge, Massachusetts, USA
- Department of Pathology, Brigham and Women’s Hospital, Boston Massachusetts, USA
| | - Wolfram Goessling
- Genetics Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Harvard–MIT Division of Health Sciences and Technology, Cambridge, Massachusetts, USA
- Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Developmental and Regenerative Biology Program, Harvard Medical School, Boston, Massachusetts, USA
- Harvard Stem Cell Institute, Cambridge, Massachusetts, USA
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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4
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Zou J, Li J, Zhong X, Tang D, Fan X, Chen R. Liver in infections: a single-cell and spatial transcriptomics perspective. J Biomed Sci 2023; 30:53. [PMID: 37430371 PMCID: PMC10332047 DOI: 10.1186/s12929-023-00945-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 06/27/2023] [Indexed: 07/12/2023] Open
Abstract
The liver is an immune organ that plays a vital role in the detection, capture, and clearance of pathogens and foreign antigens that invade the human body. During acute and chronic infections, the liver transforms from a tolerant to an active immune state. The defence mechanism of the liver mainly depends on a complicated network of intrahepatic and translocated immune cells and non-immune cells. Therefore, a comprehensive liver cell atlas in both healthy and diseased states is needed for new therapeutic target development and disease intervention improvement. With the development of high-throughput single-cell technology, we can now decipher heterogeneity, differentiation, and intercellular communication at the single-cell level in sophisticated organs and complicated diseases. In this concise review, we aimed to summarise the advancement of emerging high-throughput single-cell technologies and re-define our understanding of liver function towards infections, including hepatitis B virus, hepatitis C virus, Plasmodium, schistosomiasis, endotoxemia, and corona virus disease 2019 (COVID-19). We also unravel previously unknown pathogenic pathways and disease mechanisms for the development of new therapeutic targets. As high-throughput single-cell technologies mature, their integration into spatial transcriptomics, multiomics, and clinical data analysis will aid in patient stratification and in developing effective treatment plans for patients with or without liver injury due to infectious diseases.
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Affiliation(s)
- Ju Zou
- Hunan Key Laboratory of Viral Hepatitis, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
- Department of Infectious Diseases, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Jie Li
- Hunan Key Laboratory of Viral Hepatitis, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
- Department of Infectious Diseases, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Xiao Zhong
- Hunan Key Laboratory of Viral Hepatitis, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
- Department of Infectious Diseases, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Daolin Tang
- Department of Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - Xuegong Fan
- Hunan Key Laboratory of Viral Hepatitis, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
- Department of Infectious Diseases, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Ruochan Chen
- Hunan Key Laboratory of Viral Hepatitis, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China.
- Department of Infectious Diseases, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China.
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5
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Sigurdarson J, Eythorsson E, Bjarnason A, Bjornsson ES. Liver injury in patients with COVID-19 in comparison to patients with the pandemic influenza A (H1N1) 2009: a population-based study. Scand J Gastroenterol 2023; 58:1145-1152. [PMID: 37128725 DOI: 10.1080/00365521.2023.2204987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 04/16/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND Elevated liver tests in patients with COVID-19 are widely reported. Population-based studies utilizing a validated analysis of drug-induced liver injury (DILI), with a control group of other viral illnesses and follow-up are largely lacking. MATERIALS AND METHODS All hospitalized patients in Iceland with SARS-CoV-2 in 2020 and pandemic influenza A (H1N1) in 2009 were included in this retrospective, population-based study. Liver tests were compared between the two groups and the correlation to inflammatory markers and persistence of alanine aminotransferase (ALT) elevations were assessed. Potential DILI cases were reviewed using the Roussel Uclaf Causality Assessment Method (RUCAM). RESULTS 225 SARS-CoV-2-positive and 73 influenza A (H1N1)-positive patients were included. Liver test values were similar between the groups, except for aspartate aminotransferase (AST) which was significantly lower in COVID-19, with a mean difference of 26 U/L (95%CI 4.2-47). Ferritin elevation was positively correlated with ALT, AST and alkaline phosphatase. No patient had persistently elevated ALT in COVID-19 and none had a probable DILI. Only 3 patients had a possible DILI according to the RUCAM. CONCLUSIONS Elevated liver enzymes are not specific for COVID-19. Hyperferritinemia was associated with elevated liver tests. DILI was very rare in COVID-19 and an unlikely cause of elevated liver enzymes in COVID-19. Abnormal liver tests are nonpersistent and generally not clinically important in these patients.
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Affiliation(s)
| | - Elias Eythorsson
- Department of Internal Medicine, Landspitali University Hospital, Reykjavik, Iceland
| | - Agnar Bjarnason
- Divison of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Internal Medicine, Landspitali University Hospital, Reykjavik, Iceland
| | - Einar S Bjornsson
- Divison of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Internal Medicine, Landspitali University Hospital, Reykjavik, Iceland
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Said KB, Alsolami A, Alreshidi FS, Fathuddin A, Alshammari F, Alrashid F, Aljadani A, Aboras R, Alreshidi F, Alghozwi MH, Alshammari SF, Alharbi NF. Profiles of Independent-Comorbidity Groups in Senior COVID-19 Patients Reveal Low Fatality Associated with Standard Care and Low-Dose Hydroxychloroquine over Antivirals. J Multidiscip Healthc 2023; 16:1215-1229. [PMID: 37153358 PMCID: PMC10162097 DOI: 10.2147/jmdh.s403700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 04/03/2023] [Indexed: 05/09/2023] Open
Abstract
Introduction The lack of feasible therapies and comorbidities aggravate the COVID-19 case-fatality rate (CFR). However, reports examining CFR associations with diabetes, concomitant cardiovascular diseases, chronic kidney disease, and chronic liver disease (CLD) are limited. More studies assessing hydroxychloroquine (Hcq) and antivirals are needed. Purpose To examine associations of COVID-19 CFR in comorbid patient groups each with single comorbidities and after treatment with Hcq, favipiravir, and dexamethasone (Dex), either alone or in combination versus standard care. Methods Using statistical analysis, we descriptively determined these associations among 750 COVID-19 patient groups during the last quarter of 2021. Results A diabetes comorbidity (40%, n=299) showed twice the fatality (CFR 14%) of the others (CFR 7%; P=0.001). Hypertension (Htn) was the second-commonest comorbidity (29.5%, n=221), with similar CFR to diabetes (15% and 7% for Htn and non-Htn, respectively), but with higher significance (P=0.0006167). Although only 4% (n=30) heart failure (HF) was reported, the CFR (40%) was much higher than in those without it (8%). A similar rate (4%) for chronic kidney disease was reported, with CFRs of 33% and 9% among those with and without it, respectively (P=0.00048). Ischemic heart disease was 11% (n=74), followed by chronic liver disease (0.4%) and history of smoking (1%); however, these were not significant due to the sample sizes. Treatment indicated standard care and Hcq alone or in combination were superior (CFR of 4% and 0.5%, respectively) compared to favipiravir (25%) or Dex (38.5%) independently or in combination (35.4%). Furthermore, Hcq performed well (CFR 9%) when combined with Dex (9%; P=4.28-26). Conclusion The dominance of diabetes and other comorbidities with significant association with CFR implied existence of a common virulence mechanism. The superiority of low-dose Hcq and standard care over antivirals warrants further studies.
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Affiliation(s)
- Kamaleldin B Said
- Department of Pathology and Microbiology, College of Medicine, University of Ha’il, Ha’il, 55476, Saudi Arabia
- Genomics, Bioinformatics and Systems Biology, Carleton University, Ottawa, ON K1S 5B6, Canada
- Correspondence: Kamaleldin B Said, Department of Pathology and Microbiology, College of Medicine, University of Ha’il, Ha’il, 55476, Saudi Arabia, Tel +966500771459, Email
| | - Ahmed Alsolami
- Department of Internal Medicine, College of Medicine, University of Ha’il, Ha’il, 55476, Saudi Arabia
| | - Fayez Saud Alreshidi
- Deparmtent of Family, Community Medicine, College of Medicine, University of Ha’il, Ha’il, 55476, Saudi Arabia
| | - Anas Fathuddin
- Department of Plastic Surgery, College of Medicine, University of Ha’il, Ha’il, 55476, Saudi Arabia
| | - Fawwaz Alshammari
- Department of Dermatology, College of Medicine, University of Ha’il, Ha’il, 55476, Saudi Arabia
| | - Fauwaz Alrashid
- Department of Surgery, College of Medicine, University of Ha’il, Ha’il, 55476, Saudi Arabia
| | - Ahmed Aljadani
- Department of Internal Medicine, College of Medicine, University of Ha’il, Ha’il, 55476, Saudi Arabia
| | - Rana Aboras
- Deparmtent of Family, Community Medicine, College of Medicine, University of Ha’il, Ha’il, 55476, Saudi Arabia
| | - Fatmah Alreshidi
- Deparmtent of Family, Community Medicine, College of Medicine, University of Ha’il, Ha’il, 55476, Saudi Arabia
| | - Mohammed H Alghozwi
- Department of Pathology and Microbiology, College of Medicine, University of Ha’il, Ha’il, 55476, Saudi Arabia
| | - Suliman F Alshammari
- Department of Pathology and Microbiology, College of Medicine, University of Ha’il, Ha’il, 55476, Saudi Arabia
| | - Nawaf F Alharbi
- Department of Pathology and Microbiology, College of Medicine, University of Ha’il, Ha’il, 55476, Saudi Arabia
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Grando M, Balbi M, Zeppieri M. COVID-19-induced liver injury in adult patients: A brief overview. World J Virol 2022; 11:443-452. [PMID: 36483102 PMCID: PMC9724208 DOI: 10.5501/wjv.v11.i6.443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/07/2022] [Accepted: 10/12/2022] [Indexed: 11/23/2022] Open
Abstract
Coronavirus disease has spread worldwide since 2019, causing important pandemic issues and various social health problems to date. Little is known about the origin of this virus and the effects it has on extra-pulmonary organs. The different mechanisms of the virus and the influence it has on humans are still being studied, with hopes of finding a cure for the disease and the pathologies associated with the infection. Liver damage caused by coronavirus disease 2019 (COVID-19) is sometimes underestimated and has been of important clinical interest in the past few years. Hepatic dysfunctions can manifest in different forms which can sometimes be mild and without specific signs and symptoms or be severe with important clinical implications. There are several studies that have tried to explain the mechanism of entry (hepatotropism) of the virus into hepatocytes and the effects the virus has on this important organ. What clearly emerges from the current literature is that hepatic injury represents an important clinical aspect in the management of patients infected with COVID-19, especially in frail patients and those with comorbidities. The aim of our brief overview is to summarize the current literature regarding the forms of hepatic damage, complications, mechanisms of pathology, clinical features of liver injury, influence of comorbidities and clinical management in patients with COVID-19 infection.
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Affiliation(s)
- Martina Grando
- Department of Internal Medicine, Azienda Sanitaria Friuli Occidentale, San Vito al Tagliamento 33078, Italy
| | - Massimiliano Balbi
- Department of Internal Medicine, Azienda Sanitaria Friuli Occidentale, San Vito al Tagliamento 33078, Italy
| | - Marco Zeppieri
- Department of Ophthalmology, University Hospital of Udine, Udine 33100, Italy
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8
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Wongtanasarasin W. Cholestatic liver injury: A rare but fatal complication during and after COVID-19 infection. World J Virol 2022; 11:435-442. [PMID: 36483106 PMCID: PMC9724201 DOI: 10.5501/wjv.v11.i6.435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 09/21/2022] [Accepted: 10/19/2022] [Indexed: 11/23/2022] Open
Abstract
The 2019 coronavirus disease (COVID-19), resulting from the severe acute respiratory syndrome 2 virus, has transformed our globe and provided a new perspective on respiratory tract infections. However, COVID-19 would not be recognized as a condition restricted to only pneumonia. This narrative review was conducted by searching manuscripts in several databases, including PubMed/ MEDLINE, Web of Science, and Reference Citation Analysis, from December 2019 to July 2022. Many studies have revealed a broad spectrum of potential systemic symptoms, including biliary complications. Although biliary injury has been observed in a very low proportion of COVID-19 patients, it is associated with increased mortalities and long-term morbidities. We identify a cholangiopathy condition in individuals during infection and after recovering from severe COVID-19, defined by a significant increase in serum alkaline phosphatase and signs of bile duct injury. Understanding the pathogeneses behind this condition would help us develop new techniques to prevent these complications. This review thoroughly discusses and summarizes the current information regarding COVID-19-associated cholangiopathy. In addition, the possible explanations for COVID-19-associated cholangiopathy are presented. Since the exact pathogenesis may not be concluded, this review could provide relevant information to encourage additional investigations shortly.
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Affiliation(s)
- Wachira Wongtanasarasin
- Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, CA 95817, United States
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9
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Pita-Juarez Y, Karagkouni D, Kalavros N, Melms JC, Niezen S, Delorey TM, Essene AL, Brook OR, Pant D, Skelton-Badlani D, Naderi P, Huang P, Pan L, Hether T, Andrews TS, Ziegler CGK, Reeves J, Myloserdnyy A, Chen R, Nam A, Phelan S, Liang Y, Amin AD, Biermann J, Hibshoosh H, Veregge M, Kramer Z, Jacobs C, Yalcin Y, Phillips D, Slyper M, Subramanian A, Ashenberg O, Bloom-Ackermann Z, Tran VM, Gomez J, Sturm A, Zhang S, Fleming SJ, Warren S, Beechem J, Hung D, Babadi M, Padera RF, MacParland SA, Bader GD, Imad N, Solomon IH, Miller E, Riedel S, Porter CBM, Villani AC, Tsai LTY, Hide W, Szabo G, Hecht J, Rozenblatt-Rosen O, Shalek AK, Izar B, Regev A, Popov Y, Jiang ZG, Vlachos IS. A single-nucleus and spatial transcriptomic atlas of the COVID-19 liver reveals topological, functional, and regenerative organ disruption in patients. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2022:2022.10.27.514070. [PMID: 36324805 PMCID: PMC9628199 DOI: 10.1101/2022.10.27.514070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
The molecular underpinnings of organ dysfunction in acute COVID-19 and its potential long-term sequelae are under intense investigation. To shed light on these in the context of liver function, we performed single-nucleus RNA-seq and spatial transcriptomic profiling of livers from 17 COVID-19 decedents. We identified hepatocytes positive for SARS-CoV-2 RNA with an expression phenotype resembling infected lung epithelial cells. Integrated analysis and comparisons with healthy controls revealed extensive changes in the cellular composition and expression states in COVID-19 liver, reflecting hepatocellular injury, ductular reaction, pathologic vascular expansion, and fibrogenesis. We also observed Kupffer cell proliferation and erythrocyte progenitors for the first time in a human liver single-cell atlas, resembling similar responses in liver injury in mice and in sepsis, respectively. Despite the absence of a clinical acute liver injury phenotype, endothelial cell composition was dramatically impacted in COVID-19, concomitantly with extensive alterations and profibrogenic activation of reactive cholangiocytes and mesenchymal cells. Our atlas provides novel insights into liver physiology and pathology in COVID-19 and forms a foundational resource for its investigation and understanding.
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Affiliation(s)
- Yered Pita-Juarez
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Dimitra Karagkouni
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Nikolaos Kalavros
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Spatial Technologies Unit, HMS Initiative for RNA Medicine / Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Johannes C Melms
- Department of Medicine, Division of Hematology/Oncology, Columbia University Irving Medical Center, New York, NY, USA
- Columbia Center for Translational Immunology, New York, NY, USA
| | - Sebastian Niezen
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Division of Gastroenterology, Hepatology and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, MA, USA
| | - Toni M Delorey
- Klarman Cell Observatory, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Adam L Essene
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, MA, USA
- Division of Endocrinology, Diabetes, and Metabolism, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Boston Nutrition and Obesity Research Center Functional Genomics and Bioinformatics Core, Boston, MA, USA
| | - Olga R Brook
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Deepti Pant
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, MA, USA
- Division of Endocrinology, Diabetes, and Metabolism, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Boston Nutrition and Obesity Research Center Functional Genomics and Bioinformatics Core, Boston, MA, USA
| | - Disha Skelton-Badlani
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Division of Gastroenterology, Hepatology and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, MA, USA
| | - Pourya Naderi
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Pinzhu Huang
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Division of Gastroenterology, Hepatology and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, MA, USA
| | - Liuliu Pan
- NanoString Technologies, Inc., Seattle, WA, USA
| | | | - Tallulah S Andrews
- Ajmera Transplant Centre, Toronto General Research Institute, University Health Network, Toronto, ON, Canada
| | - Carly G K Ziegler
- Harvard Medical School, Boston, MA, USA
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Program in Health Sciences & Technology, Harvard Medical School & Massachusetts Institute of Technology, Boston, MA, USA
- Institute for Medical Engineering & Science, Massachusetts Institute of Technology, Cambridge, MA, USA
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA, USA
- Harvard Graduate Program in Biophysics, Harvard University, Cambridge, MA, USA
- Harvard Stem Cell Institute, Cambridge, MA, USA
- Program in Computational & Systems Biology, Massachusetts Institute of Technology, Cambridge, MA, USA
- Program in Immunology, Harvard Medical School, Boston, MA, USA
- Department of Chemistry, Massachusetts Institute of Technology, Cambridge, MA, USA
| | | | - Andriy Myloserdnyy
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Division of Gastroenterology, Hepatology and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, MA, USA
| | - Rachel Chen
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Division of Gastroenterology, Hepatology and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, MA, USA
| | - Andy Nam
- NanoString Technologies, Inc., Seattle, WA, USA
| | | | - Yan Liang
- NanoString Technologies, Inc., Seattle, WA, USA
| | - Amit Dipak Amin
- Department of Medicine, Division of Hematology/Oncology, Columbia University Irving Medical Center, New York, NY, USA
- Columbia Center for Translational Immunology, New York, NY, USA
| | - Jana Biermann
- Department of Medicine, Division of Hematology/Oncology, Columbia University Irving Medical Center, New York, NY, USA
- Columbia Center for Translational Immunology, New York, NY, USA
| | - Hanina Hibshoosh
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY, USA
| | - Molly Veregge
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, MA, USA
- Division of Endocrinology, Diabetes, and Metabolism, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Boston Nutrition and Obesity Research Center Functional Genomics and Bioinformatics Core, Boston, MA, USA
| | - Zachary Kramer
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, MA, USA
- Division of Endocrinology, Diabetes, and Metabolism, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Christopher Jacobs
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, MA, USA
- Division of Endocrinology, Diabetes, and Metabolism, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Boston Nutrition and Obesity Research Center Functional Genomics and Bioinformatics Core, Boston, MA, USA
| | - Yusuf Yalcin
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Division of Gastroenterology, Hepatology and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, MA, USA
| | - Devan Phillips
- Current address: Genentech, 1 DNA Way, South San Francisco, CA, USA
| | - Michal Slyper
- Current address: Genentech, 1 DNA Way, South San Francisco, CA, USA
| | | | - Orr Ashenberg
- Klarman Cell Observatory, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Zohar Bloom-Ackermann
- Infectious Disease and Microbiome Program, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Victoria M Tran
- Infectious Disease and Microbiome Program, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - James Gomez
- Infectious Disease and Microbiome Program, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Alexander Sturm
- Infectious Disease and Microbiome Program, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Shuting Zhang
- Infectious Disease and Microbiome Program, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Stephen J Fleming
- Data Sciences Platform, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Precision Cardiology Laboratory, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | | | | | - Deborah Hung
- Infectious Disease and Microbiome Program, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Genetics, Harvard Medical School, Boston, MA, USA
- Department of Molecular Biology and Center for Computational and Integrative Biology, Massachusetts General Hospital, Boston, MA, USA
| | - Mehrtash Babadi
- Data Sciences Platform, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Precision Cardiology Laboratory, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Robert F Padera
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - Sonya A MacParland
- Ajmera Transplant Centre, Toronto General Research Institute, University Health Network, Toronto, ON, Canada
- Department of Immunology, University of Toronto, Medical Sciences Building, 1 King's College Circle, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Gary D Bader
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
- The Donnelly Centre, Toronto, ON, Canada
| | - Nasser Imad
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Isaac H Solomon
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - Eric Miller
- NanoString Technologies, Inc., Seattle, WA, USA
| | - Stefan Riedel
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Caroline B M Porter
- Klarman Cell Observatory, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Alexandra-Chloé Villani
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Center for Immunology and Inflammatory Diseases, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Center for Cancer Research, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Linus T-Y Tsai
- Harvard Medical School, Boston, MA, USA
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, MA, USA
- Division of Endocrinology, Diabetes, and Metabolism, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Boston Nutrition and Obesity Research Center Functional Genomics and Bioinformatics Core, Boston, MA, USA
| | - Winston Hide
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Gyongyi Szabo
- Harvard Medical School, Boston, MA, USA
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Division of Gastroenterology, Hepatology and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, MA, USA
| | - Jonathan Hecht
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Orit Rozenblatt-Rosen
- Klarman Cell Observatory, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Current address: Genentech, 1 DNA Way, South San Francisco, CA, USA
| | - Alex K Shalek
- Harvard Medical School, Boston, MA, USA
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Program in Health Sciences & Technology, Harvard Medical School & Massachusetts Institute of Technology, Boston, MA, USA
- Institute for Medical Engineering & Science, Massachusetts Institute of Technology, Cambridge, MA, USA
- Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
- Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA, USA
- Harvard Graduate Program in Biophysics, Harvard University, Cambridge, MA, USA
- Harvard Stem Cell Institute, Cambridge, MA, USA
- Program in Computational & Systems Biology, Massachusetts Institute of Technology, Cambridge, MA, USA
- Program in Immunology, Harvard Medical School, Boston, MA, USA
- Department of Chemistry, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Benjamin Izar
- Department of Medicine, Division of Hematology/Oncology, Columbia University Irving Medical Center, New York, NY, USA
- Columbia Center for Translational Immunology, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY, USA
- Program for Mathematical Genomics, Columbia University Irving Medical Center, New York, NY, USA
- Department of Systems Biology, Columbia University Irving Medical Center, New York, NY, USA
| | - Aviv Regev
- Klarman Cell Observatory, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Current address: Genentech, 1 DNA Way, South San Francisco, CA, USA
| | - Yury Popov
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Division of Gastroenterology, Hepatology and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Z Gordon Jiang
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Division of Gastroenterology, Hepatology and Nutrition, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, MA, USA
| | - Ioannis S Vlachos
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Spatial Technologies Unit, HMS Initiative for RNA Medicine / Beth Israel Deaconess Medical Center, Boston, MA, USA
- Cancer Research Institute, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School Initiative for RNA Medicine, Boston, MA, USA
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10
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Pita-Juarez Y, Karagkouni D, Kalavros N, Melms JC, Niezen S, Delorey TM, Essene AL, Brook OR, Pant D, Skelton-Badlani D, Naderi P, Huang P, Pan L, Hether T, Andrews TS, Ziegler CGK, Reeves J, Myloserdnyy A, Chen R, Nam A, Phelan S, Liang Y, Amin AD, Biermann J, Hibshoosh H, Veregge M, Kramer Z, Jacobs C, Yalcin Y, Phillips D, Slyper M, Subramanian A, Ashenberg O, Bloom-Ackermann Z, Tran VM, Gomez J, Sturm A, Zhang S, Fleming SJ, Warren S, Beechem J, Hung D, Babadi M, Padera RF, MacParland SA, Bader GD, Imad N, Solomon IH, Miller E, Riedel S, Porter CBM, Villani AC, Tsai LTY, Hide W, Szabo G, Hecht J, Rozenblatt-Rosen O, Shalek AK, Izar B, Regev A, Popov Y, Jiang ZG, Vlachos IS. A single-nucleus and spatial transcriptomic atlas of the COVID-19 liver reveals topological, functional, and regenerative organ disruption in patients. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2022. [PMID: 36324805 DOI: 10.1101/2022.08.06.503037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
The molecular underpinnings of organ dysfunction in acute COVID-19 and its potential long-term sequelae are under intense investigation. To shed light on these in the context of liver function, we performed single-nucleus RNA-seq and spatial transcriptomic profiling of livers from 17 COVID-19 decedents. We identified hepatocytes positive for SARS-CoV-2 RNA with an expression phenotype resembling infected lung epithelial cells. Integrated analysis and comparisons with healthy controls revealed extensive changes in the cellular composition and expression states in COVID-19 liver, reflecting hepatocellular injury, ductular reaction, pathologic vascular expansion, and fibrogenesis. We also observed Kupffer cell proliferation and erythrocyte progenitors for the first time in a human liver single-cell atlas, resembling similar responses in liver injury in mice and in sepsis, respectively. Despite the absence of a clinical acute liver injury phenotype, endothelial cell composition was dramatically impacted in COVID-19, concomitantly with extensive alterations and profibrogenic activation of reactive cholangiocytes and mesenchymal cells. Our atlas provides novel insights into liver physiology and pathology in COVID-19 and forms a foundational resource for its investigation and understanding.
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11
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Richards A, Friesen M, Khalil A, Barrasa MI, Gehrke L, Jaenisch R. SARS-CoV-2 infection of human pluripotent stem cell-derived liver organoids reveals potential mechanisms of liver pathology. iScience 2022; 25:105146. [PMID: 36128218 PMCID: PMC9477603 DOI: 10.1016/j.isci.2022.105146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 07/25/2022] [Accepted: 09/12/2022] [Indexed: 11/21/2022] Open
Abstract
Although respiratory symptoms are the most prevalent disease manifestation of infection by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), infection can also damage other organs, including the brain, gut, and liver. Symptoms of liver damage are observed in nearly half of patients that succumb to severe SARS-CoV-2 infection. Here we use human-induced pluripotent stem cell-derived liver organoids (HLOs) to recapitulate and characterize liver pathology following virus exposure. Utilizing single-cell sequencing technology, we identified robust transcriptomic changes that occur in SARS-CoV-2 infected liver cells as well as uninfected bystander cells. Our results show a significant induction of many inflammatory pathways, including IFN-α, INF-γ, and IL-6 signaling. Our results further identify IL-6 signaling as a potential mechanism for liver-mediated activation of circulating macrophages.
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Affiliation(s)
- Alexsia Richards
- Whitehead Institute for Biomedical Research, Cambridge, MA 02127, USA
| | - Max Friesen
- Whitehead Institute for Biomedical Research, Cambridge, MA 02127, USA
| | - Andrew Khalil
- Whitehead Institute for Biomedical Research, Cambridge, MA 02127, USA
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, MA 02115, USA
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA 02138, USA
| | | | - Lee Gehrke
- Department of Microbiology, Harvard Medical School, Boston, MA 02115, USA
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA 02127, USA
- Department of Biology, Massachusetts Institute of Technology, Cambridge, MA 02127, USA
| | - Rudolf Jaenisch
- Whitehead Institute for Biomedical Research, Cambridge, MA 02127, USA
- Department of Biology, Massachusetts Institute of Technology, Cambridge, MA 02127, USA
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12
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Chen H, Chen Q. COVID-19 Pandemic: Insights into Interactions between SARS-CoV-2 Infection and MAFLD. Int J Biol Sci 2022; 18:4756-4767. [PMID: 35874945 PMCID: PMC9305262 DOI: 10.7150/ijbs.72461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 06/23/2022] [Indexed: 01/08/2023] Open
Abstract
COVID-19, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has become an ongoing global health pandemic. Since 2019, the pandemic continues to cast a long shadow on all aspects of our lives, bringing huge health and economic burdens to all societies. With our in-depth understanding of COVID-19, from the initial respiratory tract to the later gastrointestinal tract and cardiovascular systems, the multiorgan involvement of this infectious disease has been discovered. Metabolic dysfunction-associated fatty liver disease (MAFLD), formerly named nonalcoholic fatty liver disease (NAFLD), is a major health issue closely related to metabolic dysfunctions, affecting a quarter of the world's adult population. The association of COVID-19 with MAFLD has received increasing attention, as MAFLD is a potential risk factor for SARS-CoV-2 infection and severe COVID-19 symptoms. In this review, we provide an update on the interactions between COVID-19 and MAFLD and its underlying mechanisms.
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Affiliation(s)
- Hanfei Chen
- Cancer Center, Faculty of Health Sciences, University of Macau, Taipa, Macau SAR, China.,Centre for Precision Medicine Research and Training, Faculty of Health Sciences, University of Macau, Taipa, Macau SAR, China
| | - Qiang Chen
- Cancer Center, Faculty of Health Sciences, University of Macau, Taipa, Macau SAR, China.,Centre for Precision Medicine Research and Training, Faculty of Health Sciences, University of Macau, Taipa, Macau SAR, China.,MOE Frontier Science Centre for Precision Oncology, University of Macau, Taipa, Macau SAR, China
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13
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Săbiescu DM, Kamal AM, Kamal CK, Alexandru DO, Mitruț P. Liver damage in the context of SARS-CoV-2. Covid-19 treatment and its effects on the liver. J Med Life 2022; 15:727-734. [PMID: 35928369 PMCID: PMC9321495 DOI: 10.25122/jml-2022-0177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 05/16/2022] [Indexed: 11/21/2022] Open
Abstract
Since COVID-19 was declared a pandemic by the World Health Organization, the scientific community has tried to protect the population from the infection and its effects through multiple lines of evidence. Patients at high risk of developing severe disease were advised to protect themselves and practice effective physical distancing. Phenotypes specific to this infection need to be reviewed to understand COVID-19 and its clinical manifestations. When the pandemic began, the scientific community was concerned with the unfavorable outcome of cases with pre-existing liver disease. There have been speculations about risk factors for severe diseases such as liver disease, age, gender, and association with obesity or diabetes.
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Affiliation(s)
- Denisa Marilena Săbiescu
- Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, Craiova, Romania,Corresponding Author: Denisa Marilena Săbiescu, Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, Craiova, Romania. E-mail:
| | - Adina Maria Kamal
- Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, Craiova, Romania,Adina Maria Kamal, Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, Craiova, Romania. E-mail:
| | - Constantin Kamal Kamal
- Department of Family Medicine, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Dragos Ovidiu Alexandru
- Department of Informatics and Biostatistics, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - Paul Mitruț
- Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, Craiova, Romania
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14
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Selective COVID-19 Coinfections in Diabetic Patients with Concomitant Cardiovascular Comorbidities Are Associated with Increased Mortality. Pathogens 2022; 11:pathogens11050508. [PMID: 35631029 PMCID: PMC9145452 DOI: 10.3390/pathogens11050508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/15/2022] [Accepted: 04/21/2022] [Indexed: 02/06/2023] Open
Abstract
Coinfections and comorbidities add additional layers of difficulties into the challenges of COVID-19 patient management strategies. However, studies examining these clinical conditions are limited. We have independently investigated the significance of associations of specific bacterial species and different comorbidities in the outcome and case fatality rates among 129 hospitalized comorbid COVID-19 patients. For the first time, to best of our knowledge, we report on the predominance of Klebsiella pneumoniae and Acinetobacter baumannii in COVID-19 non-survival diabetic patients The two species were significantly associated to COVID-19 case fatality rates (p-value = 0.02186). Coinfection rates of Klebsiella pneumoniae and Acinetobacter baumannii in non-survivors were 93% and 73%, respectively. Based on standard definitions for antimicrobial resistance, Klebsiella pneumoniae and Acinetobacter baumannii were classified as multidrug resistant and extremely drug resistant, respectively. All patients died at ICU with similar clinical characterisitics. Of the 28 major coinfections, 24 (85.7%) were in non-survivor diabetic patients, implying aggravating and worsening the course of COVID-19. The rates of other comorbidities varied: asthma (47%), hypertension (79.4%), ischemic heart disease (71%), chronic kidney disease (35%), and chronic liver disease (32%); however, the rates were higher in K. pneumoniae and were all concomitantly associated to diabetes. Other bacterial species and comorbidities did not have significant correlation to the outcomes. These findings have highly significant clinical implications in the treatment strategies of COVID-19 patients. Future vertical genomic studies would reveal more insights into the molecular and immunological mechanisms of these frequent bacterial species. Future large cohort multicenter studies would reveal more insights into the mechanisms of infection in COVID-19.
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15
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Affiliation(s)
- Eleanor Barnes
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.
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16
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Ito GNW, Rodrigues VAC, Hümmelgen J, Meschino GSPG, Abou‐Rejaile GM, Brenny ID, de Castro Júnior CR, Artigas RC, Munhoz JPS, Cardoso GC, Picheth GF. COVID-19 pathophysiology and ultrasound imaging: A multiorgan review. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:326-338. [PMID: 35218034 PMCID: PMC9088355 DOI: 10.1002/jcu.23160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/05/2022] [Accepted: 02/09/2022] [Indexed: 05/09/2023]
Abstract
COVID-19 is a dynamic disease and may affect different tissues and organs as it progresses. Therefore, the impact generated by the disease in all its stages and organs requires a functional and versatile imaging technique able to detect particularities or artifacts dynamically. Ultrasonography fulfills all these requirements and exhibit several advantages relative to other imaging modalities, including portability, lower cost and biosafety. Throughout the COVID-19 pandemic, ultrasonography displayed a crucial role in the triage, monitoring, indicating organ damages and enabling individualized therapeutical decisions in COVID-19 patients. This review is dedicated to highlight the main pathological effects correlated with ultrasound changes caused by COVID-19 in the lungs, heart and liver.
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Affiliation(s)
- Giovana N. W. Ito
- School of MedicinePontifical Catholic University of ParanáCuritibaBrazil
| | | | - Juliana Hümmelgen
- School of MedicinePontifical Catholic University of ParanáCuritibaBrazil
| | | | | | - Isadora D. Brenny
- School of MedicinePontifical Catholic University of ParanáCuritibaBrazil
| | | | - Rafaela C. Artigas
- School of MedicinePontifical Catholic University of ParanáCuritibaBrazil
| | | | | | - Guilherme F. Picheth
- School of MedicinePontifical Catholic University of ParanáCuritibaBrazil
- Department of Basic PathologyFederal University of ParanáCuritibaBrazil
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17
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Ihlow J, Seelhoff A, Corman VM, Gruber AD, Dökel S, Meinhardt J, Radbruch H, Späth-Schwalbe E, Elezkurtaj S, Horst D, Herbst H. COVID-19: a fatal case of acute liver failure associated with SARS-CoV-2 infection in pre-existing liver cirrhosis. BMC Infect Dis 2021; 21:901. [PMID: 34479499 PMCID: PMC8414454 DOI: 10.1186/s12879-021-06605-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 08/23/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The detection of severe acute respiratory syndrome coronavirus (SARS-CoV-2) is challenging, particularly in post-mortem human tissues. However, there is increasing evidence for viral SARS-CoV-2 manifestation in non-respiratory tissues. In this context, it is a current matter of debate, whether SARS-CoV-2 shows hepatotropism. CASE PRESENTATION Here, we report a case of an 88-year-old women with massive SARS-CoV-2 viremia, severe jaundice and clinical signs of an acute hepatitis, who died within a few days from an acute liver failure without showing any clinical signs of pneumonia. Autopsy revealed a severe chronic and acute liver damage with bile duct infestation by SARS-CoV-2 that was accompanied by higher expressions of angiotensin-converting enzyme-2 (ACE2), Cathepsin L and transmembrane serine protease 2 (TMPRSS2). CONCLUSION Our findings indicate an enhanced biliary susceptibility to viral infection with SARS-CoV-2, that might have resulted from pre-existing severe liver damage. Furthermore, our findings emphasize the differential diagnosis of coronavirus disease 2019 (COVID-19)-associated liver failure in the clinical setting of an inexplicable jaundice.
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Affiliation(s)
- Jana Ihlow
- Institute of Pathology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| | - Alexander Seelhoff
- Department of Gastroenterology, Vivantes Netzwerk für Gesundheit GmbH Berlin, Vivantes Hospital Spandau, Neue Bergstraße 6, 13585, Berlin, Germany
| | - Victor M Corman
- Institute of Virology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Achim D Gruber
- Institute of Veterinary Pathology, Freie Universität Berlin, Robert-von-Ostertag-Straße 15, 14163, Berlin, Germany
| | - Simon Dökel
- Institute of Veterinary Pathology, Freie Universität Berlin, Robert-von-Ostertag-Straße 15, 14163, Berlin, Germany
| | - Jenny Meinhardt
- Institute of Neuropathology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Helena Radbruch
- Institute of Neuropathology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Ernst Späth-Schwalbe
- Department of Hematology, Oncology and Palliative Care, Vivantes Netzwerk für Gesundheit GmbH Berlin, Vivantes Hospital Spandau, Neue Bergstraße 6, 13585, Berlin, Germany
| | - Sefer Elezkurtaj
- Institute of Pathology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - David Horst
- Institute of Pathology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Hermann Herbst
- Department of Pathology, Vivantes Netzwerk für Gesundheit GmbH Berlin, Vivantes Hospital Neukölln, Rudower Straße 48, 12351, Berlin, Germany
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18
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An overview of SARS-COV-2-related hepatic injury. HEPATOLOGY FORUM 2021; 2:122-127. [PMID: 35784909 PMCID: PMC9138946 DOI: 10.14744/hf.2021.2021.0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 06/24/2021] [Indexed: 01/08/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative pathogen of coronavirus disease 2019 (COVID-19), is highly contagious and has a variety of clinical manifestations, including liver injury. There have been a few reports indicating acute-on chronic liver failure among COVID-19 patients, however, patients with COVID-19-related liver injury are generally asymptomatic and present with a mild to moderate elevation in serum hepatic enzymes. Severe COVID-19 patients have high rates of liver injury with poorer outcomes. The pattern of abnormalities in liver biochemical indicators may be hepatocellular, cholestatic, or mixed. Although the pathogenesis of hepatic injury is not yet completely understood, causes of liver damage include systemic inflammatory response syndrome, ischemia-reperfusion injury, side effects of medications, and underlying chronic liver disease. While viral RNA has been detected in hepatocytes, it remains unknown if the coronavirus has the capacity to cause cytopathic effects in hepatic tissue. Additionally, it is important to remember that the current upheaval to daily life and access to healthcare caused by the COVID-19 pandemic has had a significant and negative effect on other patients with chronic liver disease. The objective of this review was to summarize the current literature on COVID-19-related hepatic injury with an examination of clinical features, potential pathogenesis, and histopathological findings of this entity.
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19
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Boeckmans J, Rombaut M, Demuyser T, Declerck B, Piérard D, Rogiers V, De Kock J, Waumans L, Magerman K, Cartuyvels R, Rummens JL, Rodrigues RM, Vanhaecke T. Infections at the nexus of metabolic-associated fatty liver disease. Arch Toxicol 2021; 95:2235-2253. [PMID: 34027561 PMCID: PMC8141380 DOI: 10.1007/s00204-021-03069-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 04/29/2021] [Indexed: 02/07/2023]
Abstract
Metabolic-associated fatty liver disease (MAFLD) is a chronic liver disease that affects about a quarter of the world population. MAFLD encompasses different disease stadia ranging from isolated liver steatosis to non-alcoholic steatohepatitis (NASH), fibrosis, cirrhosis and hepatocellular carcinoma. Although MAFLD is considered as the hepatic manifestation of the metabolic syndrome, multiple concomitant disease-potentiating factors can accelerate disease progression. Among these risk factors are diet, lifestyle, genetic traits, intake of steatogenic drugs, male gender and particular infections. Although infections often outweigh the development of fatty liver disease, pre-existing MAFLD could be triggered to progress towards more severe disease stadia. These combined disease cases might be underreported because of the high prevalence of both MAFLD and infectious diseases that can promote or exacerbate fatty liver disease development. In this review, we portray the molecular and cellular mechanisms by which the most relevant viral, bacterial and parasitic infections influence the progression of fatty liver disease and steatohepatitis. We focus in particular on how infectious diseases, including coronavirus disease-19, hepatitis C, acquired immunodeficiency syndrome, peptic ulcer and periodontitis, exacerbate MAFLD. We specifically underscore the synergistic effects of these infections with other MAFLD-promoting factors.
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Affiliation(s)
- Joost Boeckmans
- Department of In Vitro Toxicology and Dermato-Cosmetology, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Brussels, Belgium.
- Clinical Laboratory, Jessa Hospital, Stadsomvaart 11, 3500, Hasselt, Belgium.
| | - Matthias Rombaut
- Department of In Vitro Toxicology and Dermato-Cosmetology, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Brussels, Belgium
| | - Thomas Demuyser
- Department of Microbiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
- Center for Neurosciences, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Brussels, Belgium
| | - Baptist Declerck
- Department of Microbiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Denis Piérard
- Department of Microbiology, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Vera Rogiers
- Department of In Vitro Toxicology and Dermato-Cosmetology, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Brussels, Belgium
| | - Joery De Kock
- Department of In Vitro Toxicology and Dermato-Cosmetology, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Brussels, Belgium
| | - Luc Waumans
- Clinical Laboratory, Jessa Hospital, Stadsomvaart 11, 3500, Hasselt, Belgium
| | - Koen Magerman
- Clinical Laboratory, Jessa Hospital, Stadsomvaart 11, 3500, Hasselt, Belgium
- Department of Immunology and Infection, Hasselt University, Martelarenlaan 42, 3500, Hasselt, Belgium
| | - Reinoud Cartuyvels
- Clinical Laboratory, Jessa Hospital, Stadsomvaart 11, 3500, Hasselt, Belgium
| | - Jean-Luc Rummens
- Clinical Laboratory, Jessa Hospital, Stadsomvaart 11, 3500, Hasselt, Belgium
| | - Robim M Rodrigues
- Department of In Vitro Toxicology and Dermato-Cosmetology, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Brussels, Belgium.
| | - Tamara Vanhaecke
- Department of In Vitro Toxicology and Dermato-Cosmetology, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090, Brussels, Belgium
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20
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Martinez MA, Franco S. Impact of COVID-19 in Liver Disease Progression. Hepatol Commun 2021; 5:1138-1150. [PMID: 34533001 PMCID: PMC8239862 DOI: 10.1002/hep4.1745] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/12/2021] [Accepted: 04/28/2021] [Indexed: 02/06/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is a novel coronavirus that causes coronavirus disease 19 (COVID-19), which has infected millions of people worldwide in only a few months. A minority, but significant number, of infected individuals require hospitalization and intensive care. From the start of this new virus pandemic, it was apparent that obese and/or diabetic individuals had a bad prognosis for COVID-19 progression, strongly suggesting an association between liver disease and severe COVID-19. Because chronic liver disease (CLD) is associated with immune dysregulation and inflammation, it is unsurprising that patients with CLD may carry a greater risk of adverse outcomes following SARS-CoV-2 infection. Initial COVID-19 data have also indicated that healthy infected individuals display abnormal liver function tests, suggesting a possible direct implication of SARS-CoV-2 in liver damage. Here we show that COVID-19 affects the liver metabolism and increases the morbidity and mortality of individuals with underlying CLD.
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Affiliation(s)
- Miguel Angel Martinez
- IrsiCaixaHospital Universitari Germans Trias i PujolUniversitat Autònoma de BarcelonaBadalonaSpain
| | - Sandra Franco
- IrsiCaixaHospital Universitari Germans Trias i PujolUniversitat Autònoma de BarcelonaBadalonaSpain
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21
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D'Amico FE, Glavas D, Noaro G, Bassi D, Boetto R, Gringeri E, De Luca M, Cillo U. Case Report: Liver Cysts and SARS-CoV-2: No Evidence of Virus in Cystic Fluid. Front Surg 2021; 8:677889. [PMID: 34222319 PMCID: PMC8249569 DOI: 10.3389/fsurg.2021.677889] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/11/2021] [Indexed: 01/08/2023] Open
Abstract
Background: In December 2019, an outbreak of pneumonia, caused by a new type of coronavirus, named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It quickly spread worldwide, resulting in a pandemic. The clinical manifestations of SARS-CoV-2 range from mild non-specific symptoms to severe pneumonia with organ function damage. In addition, up to 60% of patients have liver impairment or dysfunction, confirmed by several studies by the presence of SARS-CoV-2 in the liver tissue. Methods: We report two cases of symptomatic liver cyst requiring fenestration after recent SARS-CoV-2 infection. Both patients had hospital admission due to documented SARS-CoV-2 infection. Recently, after the infection, they developed symptoms caused by an enlarged hepatic cyst: one had abdominal pain, and the other had jaundice. They underwent surgery after two negative swab tests for SARS-CoV-2. Results: Cystic fluid was sent for microbiological test, and real-time fluorescence polymerase chain reaction COVID-19 nucleic-acid assay of the cyst fluid was found to be negative in both cases. Discussion: Although there are no current data that can document a viral contamination of cystic fluid, there are data that document a hepatotropism of COVID-19 virus. Herein we report that after viral clearance at pharyngeal and nasal swab, there is no evidence of viral load in such potential viral reservoir.
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Affiliation(s)
- Francesco Enrico D'Amico
- Department of Surgical, Oncological and Gastroenterologica Sciences (DiSCOG), University of Padova, Padua, Italy.,Hepatobiliary and Liver Transplant Surgery, Padova Teaching Hospital, Padua, Italy
| | - Dajana Glavas
- Department of Surgical, Oncological and Gastroenterologica Sciences (DiSCOG), University of Padova, Padua, Italy.,Hepatobiliary and Liver Transplant Surgery, Padova Teaching Hospital, Padua, Italy
| | - Giulia Noaro
- Department of Surgery, Montebelluna Hospital ULSS2, Montebelluna, Italy
| | - Domenico Bassi
- Hepatobiliary and Liver Transplant Surgery, Padova Teaching Hospital, Padua, Italy
| | - Riccardo Boetto
- Hepatobiliary and Liver Transplant Surgery, Padova Teaching Hospital, Padua, Italy
| | - Enrico Gringeri
- Department of Surgical, Oncological and Gastroenterologica Sciences (DiSCOG), University of Padova, Padua, Italy.,Hepatobiliary and Liver Transplant Surgery, Padova Teaching Hospital, Padua, Italy
| | - Maurizio De Luca
- Department of Surgery, Montebelluna Hospital ULSS2, Montebelluna, Italy
| | - Umberto Cillo
- Department of Surgical, Oncological and Gastroenterologica Sciences (DiSCOG), University of Padova, Padua, Italy.,Hepatobiliary and Liver Transplant Surgery, Padova Teaching Hospital, Padua, Italy
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22
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Marjot T, Webb GJ, Barritt AS, Moon AM, Stamataki Z, Wong VW, Barnes E. COVID-19 and liver disease: mechanistic and clinical perspectives. Nat Rev Gastroenterol Hepatol 2021; 18:348-364. [PMID: 33692570 PMCID: PMC7945972 DOI: 10.1038/s41575-021-00426-4] [Citation(s) in RCA: 226] [Impact Index Per Article: 75.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/04/2021] [Indexed: 02/06/2023]
Abstract
Our understanding of the hepatic consequences of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and its resultant coronavirus disease 2019 (COVID-19) has evolved rapidly since the onset of the pandemic. In this Review, we discuss the hepatotropism of SARS-CoV-2, including the differential expression of viral receptors on liver cell types, and we describe the liver histology features present in patients with COVID-19. We also provide an overview of the pattern and relevance of abnormal liver biochemistry during COVID-19 and present the possible underlying direct and indirect mechanisms for liver injury. Furthermore, large international cohorts have been able to characterize the disease course of COVID-19 in patients with pre-existing chronic liver disease. Patients with cirrhosis have particularly high rates of hepatic decompensation and death following SARS-CoV-2 infection and we outline hypotheses to explain these findings, including the possible role of cirrhosis-associated immune dysfunction. This finding contrasts with outcome data in pharmacologically immunosuppressed patients after liver transplantation who seem to have comparatively better outcomes from COVID-19 than those with advanced liver disease. Finally, we discuss the approach to SARS-CoV-2 vaccination in patients with cirrhosis and after liver transplantation and predict how changes in social behaviours and clinical care pathways during the pandemic might lead to increased liver disease incidence and severity.
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Affiliation(s)
- Thomas Marjot
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK.
| | - Gwilym J Webb
- Cambridge Liver Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Alfred S Barritt
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
| | - Andrew M Moon
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
| | - Zania Stamataki
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Vincent W Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Eleanor Barnes
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK.
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23
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Stefan N, Birkenfeld AL, Schulze MB. Global pandemics interconnected - obesity, impaired metabolic health and COVID-19. Nat Rev Endocrinol 2021; 17:135-149. [PMID: 33479538 DOI: 10.1038/s41574-020-00462-1] [Citation(s) in RCA: 265] [Impact Index Per Article: 88.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2020] [Indexed: 02/07/2023]
Abstract
Obesity and impaired metabolic health are established risk factors for the non-communicable diseases (NCDs) type 2 diabetes mellitus, cardiovascular disease, neurodegenerative diseases, cancer and nonalcoholic fatty liver disease, otherwise known as metabolic associated fatty liver disease (MAFLD). With the worldwide spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), obesity and impaired metabolic health also emerged as important determinants of severe coronavirus disease 2019 (COVID-19). Furthermore, novel findings indicate that specifically visceral obesity and characteristics of impaired metabolic health such as hyperglycaemia, hypertension and subclinical inflammation are associated with a high risk of severe COVID-19. In this Review, we highlight how obesity and impaired metabolic health increase complications and mortality in COVID-19. We also summarize the consequences of SARS-CoV-2 infection for organ function and risk of NCDs. In addition, we discuss data indicating that the COVID-19 pandemic could have serious consequences for the obesity epidemic. As obesity and impaired metabolic health are both accelerators and consequences of severe COVID-19, and might adversely influence the efficacy of COVID-19 vaccines, we propose strategies for the prevention and treatment of obesity and impaired metabolic health on a clinical and population level, particularly while the COVID-19 pandemic is present.
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Affiliation(s)
- Norbert Stefan
- Institute of Diabetes Research and Metabolic Diseases (IDM), the Helmholtz Center, Munich, Germany.
- Department of Internal Medicine IV, Division of Endocrinology, Diabetology and Nephrology, University Hospital of Tübingen, Tübingen, Germany.
- German Center for Diabetes Research (DZD), Neuherberg, Germany.
| | - Andreas L Birkenfeld
- Institute of Diabetes Research and Metabolic Diseases (IDM), the Helmholtz Center, Munich, Germany
- Department of Internal Medicine IV, Division of Endocrinology, Diabetology and Nephrology, University Hospital of Tübingen, Tübingen, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
- Department of Diabetes, School of Life Course Science, King's College London, London, UK
| | - Matthias B Schulze
- German Center for Diabetes Research (DZD), Neuherberg, Germany
- Department of Molecular Epidemiology, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
- Institute of Nutritional Science, University of Potsdam, Potsdam, Germany
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24
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Marjot T, Moon AM, Cook JA, Abd-Elsalam S, Aloman C, Armstrong MJ, Pose E, Brenner EJ, Cargill T, Catana MA, Dhanasekaran R, Eshraghian A, García-Juárez I, Gill US, Jones PD, Kennedy J, Marshall A, Matthews C, Mells G, Mercer C, Perumalswami PV, Avitabile E, Qi X, Su F, Ufere NN, Wong YJ, Zheng MH, Barnes E, Barritt AS, Webb GJ. Outcomes following SARS-CoV-2 infection in patients with chronic liver disease: An international registry study. J Hepatol 2021; 74:567-577. [PMID: 33035628 PMCID: PMC7536538 DOI: 10.1016/j.jhep.2020.09.024] [Citation(s) in RCA: 332] [Impact Index Per Article: 110.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 09/22/2020] [Accepted: 09/25/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Chronic liver disease (CLD) and cirrhosis are associated with immune dysregulation, leading to concerns that affected patients may be at risk of adverse outcomes following SARS-CoV-2 infection. We aimed to determine the impact of COVID-19 on patients with pre-existing liver disease, which currently remains ill-defined. METHODS Between 25th March and 8th July 2020, data on 745 patients with CLD and SARS-CoV-2 (including 386 with and 359 without cirrhosis) were collected by 2 international registries and compared to data on non-CLD patients with SARS-CoV-2 from a UK hospital network. RESULTS Mortality was 32% in patients with cirrhosis compared to 8% in those without (p <0.001). Mortality in patients with cirrhosis increased according to Child-Pugh class (A [19%], B [35%], C [51%]) and the main cause of death was from respiratory failure (71%). After adjusting for baseline characteristics, factors associated with death in the total CLD cohort were age (odds ratio [OR] 1.02; 1.01-1.04), Child-Pugh A (OR 1.90; 1.03-3.52), B (OR 4.14; 2.4-7.65), or C (OR 9.32; 4.80-18.08) cirrhosis and alcohol-related liver disease (OR 1.79; 1.03-3.13). Compared to patients without CLD (n = 620), propensity-score-matched analysis revealed significant increases in mortality in those with Child-Pugh B (+20.0% [8.8%-31.3%]) and C (+38.1% [27.1%-49.2%]) cirrhosis. Acute hepatic decompensation occurred in 46% of patients with cirrhosis, of whom 21% had no respiratory symptoms. Half of those with hepatic decompensation had acute-on-chronic liver failure. CONCLUSIONS In the largest such cohort to date, we demonstrate that baseline liver disease stage and alcohol-related liver disease are independent risk factors for death from COVID-19. These data have important implications for the risk stratification of patients with CLD across the globe during the COVID-19 pandemic. LAY SUMMARY This international registry study demonstrates that patients with cirrhosis are at increased risk of death from COVID-19. Mortality from COVID-19 was particularly high among patients with more advanced cirrhosis and those with alcohol-related liver disease.
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Affiliation(s)
- Thomas Marjot
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK.
| | - Andrew M Moon
- Division of Gastroenterology and Hepatology, University of North Carolina, North Carolina, USA
| | - Jonathan A Cook
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Sherief Abd-Elsalam
- Tropical Medicine and Infectious diseases Department, Tanta University, Tanta, Egypt
| | - Costica Aloman
- Department of Medicine, Section of Hepatology, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Elisa Pose
- Liver Unit, Hospital Clínic, Barcelona, Spain Institut d'Investigacions Biomèdiques, August Pi i Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Erica J Brenner
- Division of Pediatric Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Tamsin Cargill
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Maria-Andreea Catana
- Division of Gastroenterology/Hepatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Renumathy Dhanasekaran
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ahad Eshraghian
- Shiraz Transplant Center, Abu-Ali Sina Hospital, Shiraz, Iran
| | - Ignacio García-Juárez
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Upkar S Gill
- Barts Liver Centre, Barts Health NHS Trust & Barts & The London School of Medicine & Dentistry, QMUL, London, UK
| | - Patricia D Jones
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - James Kennedy
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | | | - Charmaine Matthews
- Department of Gastroenterology and Hepatology, Royal Liverpool Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - George Mells
- Cambridge Liver Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Carolyn Mercer
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Ponni V Perumalswami
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Emma Avitabile
- Liver Unit, Hospital Clínic, Barcelona, Spain Institut d'Investigacions Biomèdiques, August Pi i Sunyer, Barcelona, Spain
| | - Xialong Qi
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - Feng Su
- Division of Gastroenterology, University of Washington, Seattle, WA, USA
| | - Nneka N Ufere
- Liver Center, Gastrointestinal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yu Jun Wong
- Department of Gastroenterology & Hepatology, Changi General Hospital Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ming-Hua Zheng
- MAFLD Research Center, Department of Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China; Key Laboratory of Diagnosis and Treatment for The Development of Chronic Liver Disease, Zhejiang Province, Wenzhou, Zhejiang, China
| | - Eleanor Barnes
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Alfred S Barritt
- Division of Gastroenterology and Hepatology, University of North Carolina, North Carolina, USA
| | - Gwilym J Webb
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK; Cambridge Liver Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
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25
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Afaghi P, Lapolla MA, Ghandi K. Percutaneous microwave ablation applications for liver tumors: recommendations for COVID-19 patients. Heliyon 2021; 7:e06454. [PMID: 33748501 PMCID: PMC7966996 DOI: 10.1016/j.heliyon.2021.e06454] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 02/22/2021] [Accepted: 03/04/2021] [Indexed: 02/07/2023] Open
Abstract
Microwave ablation (MWA) is an alternative locoregional therapy to surgical resection of solid tumors in the treatment of malignancies, and is widely used for hepatic tumors. It has a slightly higher overall survival (OS) rate compared to external beam radiation therapy (EBRT), and proton beam therapy (PBT), and better long-term recurrence-free OS rate compared to radiofrequency ablation (RFA). In this paper, current commercial devices, most recent noncommercial designs, and the principles behind them alongside the recently reported developments and issues of MWA are reviewed. The paper also provides microscopic insights on effects of microwave irradiation in the body. Our review shows that MWA is a safe and effective, minimally invasive method with high ablation completion rates. However, for large tumors, the completion rates slightly decrease, and recurrences increase. Thus, for large tumors we suggest using a cooled shaft antenna or multiple antenna placements. Comparisons of the two common ablation frequencies 915 MHz and 2.45 GHz have shown inconsistent results due to non-identical conditions. This review suggests that 915 MHz devices are more effective for ablating large tumors and the theory behind MWA effects corroborates this proposition. However, for small tumors or tumors adjacent to vital organs, 2.45 GHz is suggested due to its more localized ablation zone. Among the antenna designs, the double-slot antenna with a metallic choke seems to be more effective by localizing the radiation around the tip of the antenna, while also preventing backward radiation towards the skin. The review also pertains to the use of MWA in COVID-19 patients and risk factors associated with the disease. MWA should be considered for COVID-19 patients with hepatic tumors as a fast treatment with a short recovery time. As liver injury is also a risk due to COVID-19, it is recommended to apply liver function tests to monitor abnormal levels in alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin, and other liver function indicators.
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Affiliation(s)
- Pooya Afaghi
- Department of Chemistry, University of Guelph, ON, Canada
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26
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Bai Y, Wang E, Zhao S, Li J, Zhu Y, Zhang Y, Cao L, Liu H, Dong Y, Wang F, Liang G, Liu L. Implications of Laboratory Tests in Disease Grading and Death Risk Stratification of COVID-19: A Retrospective Study in Wuhan, China. Front Med (Lausanne) 2021; 8:629296. [PMID: 33693017 PMCID: PMC7938237 DOI: 10.3389/fmed.2021.629296] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 01/18/2021] [Indexed: 01/08/2023] Open
Abstract
Background: Although laboratory tests have become an indispensable part in clinical practice, its application in severity classification and death risk stratification of COVID-19 remains unvalidated. This study aims to explore the significance of laboratory tests in the management of COVID-19. Methods: In 3,342 hospitalized patients with COVID-19, those of mild or moderate subtype were categorized into the non-severe group, while those of severe or critical subtype were categorized into the severe group. Initial laboratory data were analyzed and compared according to disease severity and outcome. Diagnostic models for the severe group were generated on risk factors identified by logistic regression and receiver operating characteristic (ROC) analyses. Cox regression and ROC analyses on risk factors were utilized to construct prognostic models. Results: In identification of patients in the severe group, while age, neutrophil-to-lymphocyte ratio, and α-hydroxybutyrate dehydrogenase were identified as independent predictors, the value of combination of them appears modest [area under the curve (AUC) = 0.694]. Further ROC analyses indicated that among patients in the severe group, laboratory indices had a favorable value in identifying patients of critical subtype rather than severe subtype. For death outcome, IL-6, co-existing cerebrovascular disease, prothrombin time activity, and urea nitrogen were independent risk factors. An IL-6 single-parameter model was finalized for distinguishing between fatal and recovered individuals (AUC = 0.953). Finally, a modified death risk stratification strategy based on clinical severity and IL-6 levels enables more identification of non-survivors in patients with non-critical disease. Conclusions: Laboratory screening provides a useful tool for COVID-19 management in identifying patients with critical condition and stratifying risk levels of death.
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Affiliation(s)
- Yang Bai
- Department of Gastroenterology, Tangdu Hospital of Fourth Military Medical University, Xi'an, China.,Department of Neurosurgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Enxin Wang
- Department of Medical Affairs, Air Force Hospital of Western Theater Command, Chengdu, China
| | - Shoujie Zhao
- Department of General Surgery, Tangdu Hospital of Fourth Military Medical University, Xi'an, China
| | - Jing Li
- Department of Digestive Disease, Shanxi Bethuen Hospital of Shanxi Academy of Medical Sciences, Taiyuan, China
| | - Yejing Zhu
- Department of General Surgery, Tangdu Hospital of Fourth Military Medical University, Xi'an, China
| | - Yongchao Zhang
- Department of Medical Affairs, Air Force Hospital of Western Theater Command, Chengdu, China
| | - Liang Cao
- Department of Traditional Chinese Medicine, Tangdu Hospital of Fourth Military Medical University, Xi'an, China
| | - Haitao Liu
- Department of Cardiology, Xijing Hospital of Fourth Military Medical University, Xi'an, China
| | - Yushu Dong
- Department of Neurosurgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Fang Wang
- Department of Dermatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Division of Dermatology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, United States
| | - Guobiao Liang
- Department of Neurosurgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Lei Liu
- Department of Gastroenterology, Tangdu Hospital of Fourth Military Medical University, Xi'an, China
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27
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Bertolini A, van de Peppel IP, Bodewes FA, Moshage H, Fantin A, Farinati F, Fiorotto R, Jonker JW, Strazzabosco M, Verkade HJ, Peserico G. Abnormal Liver Function Tests in Patients With COVID-19: Relevance and Potential Pathogenesis. Hepatology 2020; 72:1864-1872. [PMID: 32702162 PMCID: PMC7404414 DOI: 10.1002/hep.31480] [Citation(s) in RCA: 176] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 06/19/2020] [Accepted: 07/16/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Anna Bertolini
- Department of PediatricsUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Ivo P. van de Peppel
- Department of PediatricsUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Frank A.J.A. Bodewes
- Department of PediatricsUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Han Moshage
- Department of Gastroenterology and HepatologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Alberto Fantin
- Department of GastroenterologyVeneto Institute of OncologyPadovaItaly
| | - Fabio Farinati
- Gastroenterology UnitDepartment of Surgery, Oncology and GastroenterologyUniversity of PadovaPadovaItaly
| | - Romina Fiorotto
- Section of Digestive Diseases, Liver CenterDepartment of Internal MedicineYale UniversityNew HavenCT
| | - Johan W. Jonker
- Department of PediatricsUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Mario Strazzabosco
- Section of Digestive Diseases, Liver CenterDepartment of Internal MedicineYale UniversityNew HavenCT
| | - Henkjan J. Verkade
- Department of PediatricsUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Giulia Peserico
- Department of GastroenterologyVeneto Institute of OncologyPadovaItaly
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Boettler T, Marjot T, Newsome PN, Mondelli MU, Maticic M, Cordero E, Jalan R, Moreau R, Cornberg M, Berg T. Impact of COVID-19 on the care of patients with liver disease: EASL-ESCMID position paper after 6 months of the pandemic. JHEP Rep 2020; 2:100169. [PMID: 32835190 PMCID: PMC7402276 DOI: 10.1016/j.jhepr.2020.100169] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 07/26/2020] [Indexed: 02/06/2023] Open
Abstract
During the early stages of the coronavirus disease 2019 (COVID-19) pandemic, EASL and ESCMID published a position paper to provide guidance for physicians involved in the care of patients with chronic liver disease. While some healthcare systems are returning to a more normal routine, many countries and healthcare systems have been, or still are, overwhelmed by the pandemic, which is significantly impacting on the care of these patients. In addition, many studies have been published focusing on how COVID-19 may affect the liver and how pre-existing liver diseases might influence the clinical course of COVID-19. While many aspects remain poorly understood, it has become increasingly evident that pre-existing liver diseases and liver injury during the disease course must be kept in mind when caring for patients with COVID-19. This review should serve as an update on the previous position paper, summarising the evidence for liver disease involvement during COVID-19 and providing recommendations on how to return to routine care wherever possible.
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Key Words
- ACE2, angiotensin-converting enzyme 2
- ACLF, acute-on-chronic liver failure
- COVID-19
- COVID-19, coronavirus disease 2019
- Cancer
- Cirrhosis
- ERC, endoscopic retrograde cholangiography
- HCC, hepatocellular carcinoma
- IL-6, interleukin-6
- LT, liver transplant
- Liver
- MELD, model for end-stage liver disease
- NAFLD
- NAFLD, non-alcoholic fatty liver disease
- NASH, non-alcoholic steatohepatitis
- OGD, oesophagogastroduodenoscopy
- SARS-CoV-2, severe acute respiratory syndrome coronavirus 2
- Telemedicine
- Transplantation
- ULN, upper limit of normal
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Affiliation(s)
- Tobias Boettler
- Department of Medicine II, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Thomas Marjot
- Oxford Liver Unit, Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, University of Oxford, UK
| | - Philip N. Newsome
- National Institute for Health Research, Birmingham Biomedical Research Centre at University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Centre for Liver & Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Mario U. Mondelli
- Division of Infectious Diseases and Immunology, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Mojca Maticic
- Clinic for Infectious Diseases and Febrile Illnesses, University Medical Centre Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Slovenia
| | - Elisa Cordero
- Department of Medicine, University of Seville, Clinical Unit of Infectious Diseases University Hospital Virgen del Rocio, Institute of Biomedicine, Sevilla, CSIC, Spain
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, London, UK
| | - Richard Moreau
- Inserm, Université de Paris, U1149, Centre de Recherche sur l'Inflammation (CRI), UMRS1149, Paris, France
- Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
| | - Markus Cornberg
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
- Centre for Individualised Infection Medicine (CIIM), Hannover, Germany
| | - Thomas Berg
- Division of Hepatology, Department of Medicine II, Leipzig University Medical Center, Leipzig, Germany
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