Abnormal liver-related biomarkers in COVID-19 patients and the role of prealbumin

Mechanisms of severe acute respiratory syndrome coronavirus-2 induced liver damage and alteration of some liver biomarkers: A review

The most serious problem for people suffering from severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection is liver damage. The liver is a frequently affected organ due to the metabolizing and detoxifying functions of several endogenous and exogenous molecules. In COVID-19-affected individuals, even moderate loss of hepatic function could dramatically affect the therapeutic efficacy of antiviral drugs metabolized in the liver. The clear mechanism of hepatocellular damage from SARS-CoV-2 infection is not fully understood. The main objective of this review is to identify potential mechanisms of SARS-2 induced liver damage, treatment outcomes in SARS-CoV-2-infected patients, and future direction. Electronic databases including Web of Science, Google Scholar, MEDLINE, Scopus, and Cochrane library were used to systematically search without limitation of publication date and status. Observational, retrospective cohort, prospective case-control, cohort studies, cross-sectional studies, or clinical trials were included. Liver damage in coronavirus patients is characterized by histopathological changes and abnormal elevation of some liver function tests. These abnormalities include elevation of Alanine aminotransferase, Aspartate aminotransferase, Gamma-glutamyl transferase, Alkaline phosphatase, and Serum bilirubin levels. Histopathological changes of the liver might consist of complete or partial thrombosis of the portal and sinusoidal vessels, portal tract fibrosis, and focally markedly enlarged and fibrotic hepatocytes. Understanding the fundamental molecular and immunological processes of COVID-19-related liver injury is essential for the selection of appropriate drugs and the logical development of successful treatment.

Features of Liver Injury in COVID-19 Pathophysiological, Biological and Clinical Particularities

The outbreak of the coronavirus pandemic in March 2020 has caused unprecedented pressure on public health and healthcare. The spectrum of COVID-19 onset is large, from mild cases with minor symptoms to severe forms with multi-organ dysfunction and death. In COVID-19, multiple organ damage has been described, including lung damage, acute kidney injury, liver damage, stroke, cardiovascular and digestive tract disorders. The aspects of liver injury are different, sometimes presenting with only a slight increase in liver enzymes, but sometimes with severe liver injury, leading to acute liver failure requiring liver transplantation. In patients with chronic liver disease, especially liver cirrhosis, immune dysfunction can increase the risk of infection. Immune dysfunction has a multifactorial physiopathological mechanism, implying a complement system and macrophage activation, lymphocyte and neutrophil activity dysfunction, and intestinal dysbiosis. This review aims to evaluate the most relevant studies published in the last years related to the etiopathogenetic, biochemical, and histological aspects of liver injury in patients diagnosed with COVID-19. Liver damage is more evident in patients with underlying chronic liver disease, with a significantly higher risk of developing severe outcomes of COVID-19 and death. Systemic inflammation, coagulation disorders, endothelial damage, and immune dysfunction explain the pathogenic mechanisms involved in impaired liver function. Although various mechanisms of action of SARS-CoV-2 on the liver cell have been studied, the impact of the direct viral effect on hepatocytes is not yet established.

Prevention, diagnostic evaluation, management and prognostic implications of liver disease in critically ill patients with COVID-19

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2, broke out in December 2019 in Wuhan city of China and spread rapidly worldwide. Therefore, by March 2020, the World Health Organization declared the disease a global pandemic. Apart from the respiratory system, various other organs of the human body are also seriously affected by the virus. Liver injury in patients with a severe form of COVID-19 is estimated to be 14.8%-53.0%. Elevated levels of total bilirubin, aspartate aminotransferase and alanine aminotransferase and low levels of serum albumin and prealbumin are the main laboratory findings. Patients with pre-existing chronic liver disease and cirrhosis are much more prone to develop severe liver injury. This literature review presented the recent scientific findings regarding the pathophysiological mechanisms responsible for liver injury in critically ill patients with COVID-19, the various interactions between drugs used to treat the disease and the function of the liver and the specific tests providing the possibility of early diagnosis of severe liver injury in these patients. Moreover, it highlighted the burden that COVID-19 put on health systems worldwide and its effect on transplant programs and the care provided to critically ill patients in general and particularly to those with chronic liver disease.

Biomarker based biosensors: An opportunity for diagnosis of COVID-19

Early diagnosis and treatment of diseases are crucial research areas of human health. For early diagnosis, one method that has proven efficient is the detection of biomarkers which can provide real-time and accurate biological information. Most biomarker detection is currently carried out at localised dedicated laboratories using large and automated analysers, increasing waiting time and costs. Smaller, faster, and cheaper devices could potentially replace these time-consuming laboratory analyses and make analytical results available as point-of-care diagnostics. Innovative biosensor-based strategies could allow biomarkers to be tested reliably in a decentralised setting. Early diagnosis of COVID-19 patients has a key role in order to use quarantine and treatment strategies in a timely manner. Raised levels of several biomarkers in COVID-19 patients are associated with respiratory infections or dysfunction of various organs. Through clinical studies of COVID-19 patient biomarkers such as ferritin, Interleukins, albumin and …are found to reveals significant differences in their excretion ranges from healthy patients and patients with SARS-CoV-2, in addition to the development of biomarkers based biosensor such as stated biomarkers can be used and to investigate more specific biomarkers further proteomic analysis can be performed. This review presents several biomarker alterations in COVID-19 patients such as salivary, circulatory, coagulation, cardiovascular, renal, liver, C-reactive protein (CRP), immunological and inflammatory biomarkers. Also, biomarker sensors based on electrochemical, optical, and lateral flow characteristics which have potential applications for SARS-COV-2 in the recent COVID-19 pandemic, will be discussed.

Abnormal Liver Biochemistry Tests and Acute Liver Injury in COVID-19 Patients: Current Evidence and Potential Pathogenesis

Globally, millions of persons have contracted the coronavirus disease 2019 (COVID-19) over the past several months, resulting in significant mortality. Health care systems are negatively impacted including the care of individuals with cancers and other chronic diseases such as chronic active hepatitis, cirrhosis and hepatocellular carcinoma. There are various probable pathogenic mechanisms that have been presented to account for liver injury in COVID-19 patients such as hepatotoxicity cause by therapeutic drugs, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection of the bile duct cells and hepatocytes, hypoxia and systemic inflammatory response. Liver biochemistry tests such as aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyl transferase (GGT) and alkaline phosphatase (ALP) are deranged in COVID-19 patients with liver injury. Hepatocellular damage results in the elevation of serum AST and ALT levels in early onset disease while a cholestatic pattern that develops as the disease progress causes higher levels of ALP, GGT, direct and total bilirubin. These liver biochemistry tests are prognostic markers of disease severity and should be carefully monitored in COVID-19 patients. We conducted a systematic review of abnormal liver biochemistry tests in COVID-19 and the possible pathogenesis involved. Significant findings regarding the severity, hepatocellular pattern, incidence and related clinical outcomes in COVID-19 patients are highlighted.

Low Serum Albumin Predicts Severe Outcomes in COVID-19 Infection: A Single-Center Retrospective Case-Control Study

Background

Coronavirus disease 2019 (COVID-19) can cause serious complications such as multiorgan failure and death which are difficult to predict. We conducted this retrospective case-control observational study with the hypothesis that low serum albumin at presentation can predict serious outcomes in COVID-19 infection.

Methods

We included severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcriptase-polymerase chain reaction (RT-PCR) confirmed, hospitalized patients from March to July 2020 in a tertiary care hospital in the USA. Patients were followed for 21 days for the development of the primary endpoint defined as the composite outcome which included acute encephalopathy, acute kidney injury, the requirement of new renal replacement therapy, acute hypercoagulability, acute circulatory failure, new-onset heart failure, acute cardiac injury, acute arrhythmia, acute respiratory distress syndrome (ARDS), high flow oxygen support, intensive care unit (ICU) stay, mechanical ventilation or death; and the secondary endpoint of death only. Univariate and multivariate logistic regression analyses were performed to study the effect of albumin level and outcomes.

Results

The mean age was 56.76 years vs. 55.67 years (P = 0.68) in the normal albumin vs. the low albumin group. We noticed an inverse relationship between serum albumin at presentation and serious outcomes. The low albumin group had a higher composite outcome (93.88% vs. 6.12%, P < 0.05) and higher mortality (13.87% vs. 2.38%, P < 0.05) in comparison to the normal albumin group. The multivariate logistic regression analysis revealed higher odds of having composite outcomes with lower albumin group (odds ratio (OR) 10.88, 95% confidence interval (CI) 4.74 - 24.97, P < 0.05). In the subgroup analysis, the multivariate logistic regression analysis revealed higher odds of having composite outcomes with the very low albumin group (OR 7.94, 95% CI 1.70 - 37.14, P < 0.05).

Conclusions

Low serum albumin on presentation in COVID-19 infection is associated with serious outcomes not limited to mortality. The therapeutic option of albumin infusion should be investigated.

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

With the rapid development of research on coronavirus disease 2019 (COVID-19), more and more attention has been drawn to its damage to extrapulmonary organs. There are increasing lines of evidence showing that liver injury is closely related to the severity of COVID-19, which may have an adverse impact on the progression and prognosis of the patients. What is more, severe acute respiratory syndrome coronavirus-2 infection, cytokine storm, ischemia/hypoxia reperfusion injury, aggravation of the primary liver disease and drug-induced liver injury may all contribute to the hepatic damage in COVID-19 patients; although, the drug-induced liver injury, especially idiosyncratic drug-induced liver injury, requires further causality confirmation by the updated Roussel Uclaf Causality Assessment Method published in 2016. Up to now, there is no specific regimen for COVID-19, and COVID-19-related liver injury is mainly controlled by symptomatic and supportive treatment. Here, we review the clinical features of abnormal liver enzymes in COVID-19 and pathogenesis of COVID-19-related liver injury based on the current evidence, which may provide help for clinicians and researchers in exploring the pathogenesis and developing treatment strategies.

Serum Prealbumin Concentrations, COVID-19 Severity, and Mortality: A Systematic Review and Meta-Analysis

Excessive inflammation and malnutrition are associated with coronavirus disease 2019 (COVID-19) severity and mortality. Combined biomarkers of malnutrition and inflammation, such as serum prealbumin, might be particularly attractive for early risk stratification. We conducted a systematic review and meta-analysis of studies reporting serum prealbumin in patients with COVID-19. We searched PubMed, Web of Science and Scopus, between January and November 2020, for studies reporting data on serum prealbumin, COVID-19 severity, defined as severe illness, prolonged viral load, receiving mechanical ventilation or admitted to intensive care unit (ICU), and mortality. Nineteen studies in 4,616 COVID-19 patients were included in the meta-analysis. Pooled results showed that serum prealbumin concentrations were significantly lower in patients with severe disease and non-survivors (standard mean difference, SMD, −0.92, 95% CI, −1.10 to −0.74, P < 0.001). Extreme heterogeneity was observed (I² = 77.9%; P < 0.001). In sensitivity analysis, the effect size was not significantly affected when each study was in turn removed (range between −0.86 and −0.95). The Begg's (P = 0.06) and Egger's t-tests (P = 0.26) did not show publication bias. Pooled SMD values were significantly and negatively associated with age (t = −2.18, P = 0.045) and C-reactive protein (t = −3.85, P = 0.002). In our meta-analysis, lower serum prealbumin concentrations were significantly associated with COVID-19 severity and mortality. This combined marker of malnutrition and inflammation might assist with early risk stratification and management in this group.