Progress in the Clinical Features and Pathogenesis of Abnormal Liver Enzymes in Coronavirus Disease 2019

Liver Enzymes and Inflammatory Markers Among Severely Ill COVID-19 Patients: A Retrospective Case-Control Study in Telangana

Introduction The COVID-19 pandemic originated in Wuhan, China, and swiftly spread across all continents. The respiratory system is the most affected in people who acquire sickness as a result of SARS-CoV-2. However, the virus can also affect other systems. The COVID-19 pandemic has become one of the most fatal infectious diseases in the recent past. Patients present with symptoms of fever, cough, tiredness, loss of taste or smell, sore throat, headache, and diarrhea. Objective This study intends to evaluate how COVID-19 has shown its effects on the well-being of the liver by collecting and correlating the data of the liver enzymes and inflammatory markers among hospitalized COVID-19 patients with age- and sex-matched healthy controls.  Materials and methods A retrospective case-control study that included 200 patients diagnosed and hospitalized with COVID-19 was compared with an equal number of age- and sex-matched healthy control groups without COVID-19 at RVM Institute of Medical Sciences and Research Centre (RVMIMS & RC), a tertiary care teaching hospital in Siddipet, Telangana, India. Liver function tests (LFTs) and inflammatory markers were evaluated in both groups.  Results Out of 200 patients, 179 (89.5%) had elevated alanine transaminase (ALT), 191 (95.5%) had elevated aspartate aminotransferase (AST), 33 (16.5%) had elevated alkaline phosphatase (ALP), and 183 (91.5%) showed elevated D-dimer levels. All the patients had elevated interleukin-6 (IL-6) and C-reactive protein (CRP) levels. Conclusion COVID-19 patients have exhibited elevations in liver enzyme panels and inflammatory markers. Further research and follow-up studies may aid in understanding the role of the well-being of the liver in patients affected by COVID-19. Considering the emergence of newer COVID-19 strains, we recommend LFT to patients who test positive for the virus to monitor prognosis and guide treatment protocols through this study.

A Case of Severe Hepatitis in Infant Twins With COVID-19

We report a case of nine-month-old twins who presented with bright green diarrhea along with progressively worsening jaundice over one week. On initial evaluation, they were found to have significantly elevated liver enzymes, bilirubin, and alkaline phosphatase levels but without signs of liver failure. They were tested for multiple causes of liver injury including autoimmune and infectious etiologies, which were negative as well. Both twins were incidentally found to be positive for COVID-19 on testing per hospital protocol but did not have any respiratory symptoms. They were monitored closely during their hospital stay and showed clinical stability but with only slight improvement in abnormal lab levels. Ultimately, they were discharged with close outpatient follow-up. They demonstrated full resolution of all lab abnormalities and symptoms two months post discharge.

An analysis of silybin meglumine tablets in the treatment of drug-induced liver injury as assessed for causality with the updated Roussel Uclaf Causality Assessment Method using a nationwide database

AIM

Drug-induced liver injury (DILI) poses significant challenges to clinical practice. Currently, there is no recommended therapy to treat DILI; therefore, it is vital to explore new therapeutic agents. This study aimed to investigate the efficacy and safety of silybin meglumine tablets in treating DILI.

METHODS

This study analysed 34 296 DILI cases assessed by the updated RUCAM from a nationwide database. A total of 301 patients with RUCAM scores ≥6 were directly enrolled in this study, while an additional 340 patients with RUCAM scores <6 who were adjudged as probable DILI by a panel of three hepatologists were also included in the analysis. The enrolled patients were divided into the silybin meglumine group and the control group. The propensity score matching (PSM) method was used to obtain comparable characteristics between the two groups.

RESULTS

There were 129 cases in the silybin meglumine group and 512 cases in the control group. After applying PSM, 129 matched pairs were obtained. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) resumption rates in the silybin meglumine group were significantly higher than the control group (58.91% vs. 20.93%, P ≤ .0001 and 63.49% vs. 37.50%, P ≤ .0001). The univariate and multivariate logistic regression analysis revealed that grouping factor (odds raio [OR], 5.42; 95% confidenxe interval [CI], 3.12-9.39; P < .0001 and OR, 6.10; 95% CI, 2.98-12.48; P < .0001) and ALT levels (OR, 0.95; 95% CI, 0.93-0.98; P = .0015 and OR, 0.95; 95% CI, 0.92-0.99; P = .0157) were essential influencing factors for ALT normalization.

CONCLUSIONS

Silybin meglumine tablets are safe and effective in DILI treatment. Large-scale and randomized controlled trials are required to further confirm their efficacy.

Commentary on COVID-19-induced liver injury in various age and risk groups

Towards the end of 2019, a new type of coronavirus, severe acute respiratory syndrome, emerged in the city of Wuhan in China's Hubei Province. The first occurrence was described as a case of pneumonia. Coronavirus disease 2019 (COVID-19) can progress primarily with symptoms varying from a mild upper respiratory tract infection to severe pneumonia, acute respiratory distress syndrome, and death. Determining the mechanisms of action of this virus, which can affect all systems including gastrointestinal, is vital for predicting the progression of the disease and managing its treatment. It is important to demonstrate the mechanisms of action of COVID-19 in patients without a previously known chronic or systemic disease. Although there is still no specific treatment for the virus, various algorithms have been created. As a result of the applied algorithms, the response to the treatment was satisfactory in some patients, while unexpected side effects occurred in some patients. It helps to clarify whether the unwanted effects that occur are due to the effect of the disease or the side effects of the drugs used in the treatment. There is currently increasing interest in COVID-19 interaction with liver tissue. Therefore, we would like to discuss the details of liver injury/dysfunction in the current literature.

COVID-19 and hepatic injury: cellular and molecular mechanisms in diverse liver cells

The coronavirus disease 2019 (COVID-19) represents a global health and economic challenge. Hepatic injuries have been approved to be associated with severe acute respiratory syndrome coronavirus (SARS-CoV-2) infection. The viral tropism pattern of SARS-CoV-2 can induce hepatic injuries either by itself or by worsening the conditions of patients with hepatic diseases. Besides, other factors have been reported to play a crucial role in the pathological forms of hepatic injuries induced by SARS-CoV-2, including cytokine storm, hypoxia, endothelial cells, and even some treatments for COVID-19. On the other hand, several groups of people could be at risk of hepatic COVID-19 complications, such as pregnant women and neonates. The present review outlines and discusses the interplay between SARS-CoV-2 infection and hepatic injury, hepatic illness comorbidity, and risk factors. Besides, it is focused on the vaccination process and the role of developed vaccines in preventing hepatic injuries due to SARS-CoV-2 infection.

Liver Injury in COVID-19 Patients with Drugs as Causatives: A Systematic Review of 996 DILI Cases Published 2020/2021 Based on RUCAM as Causality Assessment Method

Patients with coronavirus disease 19 (COVID-19) commonly show abnormalities of liver tests (LTs) of undetermined cause. Considering drugs as tentative culprits, the current systematic review searched for published COVID-19 cases with suspected drug-induced liver injury (DILI) and established diagnosis using the diagnostic algorithm of RUCAM (Roussel Uclaf Causality Assessment Method). Data worldwide on DILI cases assessed by RUCAM in COVID-19 patients were sparse. A total of 6/200 reports with initially suspected 996 DILI cases in COVID-19 patients and using all RUCAM-based DILI cases allowed for a clear description of clinical features of RUCAM-based DILI cases among COVID-19 patients: (1) The updated RUCAM published in 2016 was equally often used as the original RUCAM of 1993, with both identifying DILI and other liver diseases as confounders; (2) RUCAM also worked well in patients treated with up to 18 drugs and provided for most DILI cases a probable or highly probable causality level for drugs; (3) DILI was preferentially caused by antiviral drugs given empirically due to their known therapeutic efficacy in other virus infections; (4) hepatocellular injury was more often reported than cholestatic or mixed injury; (5) maximum LT values were found for alanine aminotransferase (ALT) 1.541 U/L and aspartate aminotransferase (AST) 1.076 U/L; (6) the ALT/AST ratio was variable and ranged from 0.4 to 1.4; (7) the mean or median age of the COVID-19 patients with DILI ranged from 54.3 to 56 years; (8) the ratio of males to females was 1.8–3.4:1; (9) outcome was favorable for most patients, likely due to careful selection of the drugs and quick cessation of drug treatment with emerging DILI, but it was fatal in 19 patients; (10) countries reporting RUCAM-based DILI cases in COVID-19 patients included China, India, Japan, Montenegro, and Spain; (11) robust estimation of the percentage contribution of RUCAM-based DILI for the increased LTs in COVID-19 patients is outside of the current scope. In conclusion, RUCAM-based DILI with its clinical characteristics in COVID-19 patients and its classification as a confounding variable is now well defined, requiring a new correct description of COVID-19 features by removing DILI characteristics as confounders.

Drug-Induced Liver Injury in COVID-19 Patients: A Systematic Review

Introduction: The severity of COVID-19 may be correlated with the risk of liver injury development. An increasing number of studies indicate that degrees of hepatotoxicity has been associated with using some medications in the management of COVID-19 patients. However, limited studies had systematically investigated the evidence of drug-induced liver injury (DILI) in COVID-19 patients. Thus, this study aimed to examine DILI in COVID-19 patients. Methods: A systematic search was carried out in PubMed/Medline, EMBASE, and Web of Science up to December 30, 2020. Search items included "SARS-CoV-2", "Coronavirus," COVID-19, and liver injury. Results: We included 22 related articles. Among included studies, there was five case report, five case series, four randomizes control trial (RCT), seven cohort studies, and one cross-sectional study. The drugs included in this systematic review were remdesivir, favipiravir, tocilizumab, hydroxychloroquine, and lopinavir/ritonavir. Among included studies, some studies revealed a direct role of drugs, while others couldn't certainly confirm that the liver injury was due to SARS-CoV-2 itself or administration of medications. However, a significant number of studies reported that liver injury could be attributable to drug administration. Discussion: Liver injury in COVID-19 patients could be caused by the virus itself or the administration of some types of drug. Intensive liver function monitoring should be considered for patients, especially patients who are treated with drugs such as remdesivir, lopinavir/ritonavir, and tocilizumab.