Inactivated vaccines reduce the risk of liver function abnormality in NAFLD patients with COVID-19: a multi-center retrospective study

BACKGROUND

Abnormal liver function was frequently observed in nonalcoholic fatty liver disease (NAFLD) patients infected with SARS-CoV-2. Our aim was to explore the effect of SARS-CoV-2 inactivated vaccines on liver function abnormality among NAFLD patients with COVID-19.

METHODS

The multi-center retrospective cohort included 517 NAFLD patients with COVID-19 from 1 April to 30 June 2022. Participants who received 2 doses of the vaccine (n = 274) were propensity score matched (PSM) with 243 unvaccinated controls. The primary outcome was liver function abnormality and the secondary outcome was viral shedding duration. Logistic and Cox regression models were used to calculate the odds ratio (OR) and hazard ratio (HR) for the outcomes. Sensitivity analysis was conducted to assess robustness.

FINDINGS

PSM identified 171 pairs of vaccinated and unvaccinated patients. Liver function abnormality was less frequent in the vaccinated group (adjusted OR, 0.556 [95% CI (confidence interval), 0.356-0.869], p = 0.010). Additionally, the vaccinated group demonstrated a lower incidence of abnormal bilirubin levels (total bilirubin: adjusted OR, 0.223 [95% CI, 0.072-0.690], p = 0.009; direct bilirubin: adjusted OR, 0.175 [95% CI, 0.080-0.384], p < 0.001) and shorter viral shedding duration (adjusted HR, 0.798 [95% CI, 0.641-0.994], p = 0.044) than the unvaccinated group. Further subgroup analysis revealed similar results, while the sensitivity analyses indicated consistent findings.

INTERPRETATION

SARS-CoV-2 vaccination in patients with NAFLD may reduce the risk of liver dysfunction during COVID-19. Furthermore, vaccination demonstrated beneficial effects on viral shedding in the NAFLD population.

FUNDING

23XD1422700, Tszb2023-01, Zdzk2020-10, Zdxk2020-01, 2308085J27 and JLY20180124.

Elevated total and direct bilirubin are associated with acute complicated appendicitis: a single-center based study in Saudi Arabia

BACKGROUND

Appendicitis is the most common abdominal surgical emergency and up to our knowledge no previous studies have been conducted in Saudi Arabia particularly at Qassim region and this study aimed to determine a total and direct bilirubin as a predictor of acute complicated appendicitis.

METHODS

Observational retrospective study that included patients admitted under the general surgery department with a diagnosis of acute appendicitis at King Saud Hospital, Unaizah, Saudi Arabia. Data on age, gender, BMI, diabetes mellitus, total and direct bilirubin, AST, ALT, sodium, and WBCs levels were obtained.

RESULT

Among the overall study population of 158 patients, the age median [IQR] was 24.5 [19-31], males were 99 (62.7%), and complicated appendicitis was 33 (20.9%). The multivariable analysis revealed that both elevated total and direct bilirubin are associated with complicated appendicitis (aOR = 3.79, 95% CI: 1.67-8.48, P = 0.001) and (aOR = 4.74, 95% CI: 2.07-10.86, P < 0.001) respectively. A receiver operating characteristic curve showed the best cutoff value of total and direct bilirubin as ≥ 15 µmol/L and ≥ 5 µmol/L respectively, with a sensitivity of 57.6%, and specificity of 73.6% for elevated total bilirubin, and a sensitivity of 54.6%, and specificity of 80% for elevated direct bilirubin.

CONCLUSION

Elevated total and direct bilirubin are associated with acute complicated appendicitis in this setting. However, it should be supportive factor for acute complicated appendicitis and not considered as standalone diagnostic test.

Direct bilirubin: A predictor of hematoma expansion after intracerebral hemorrhage

BACKGROUND

Previous evidence demonstrated that several biomarkers involved in the pathological process of coagulation/hemostasis dysfunction, impairment of brain vascular integrity and inflammation are associated with hematoma expansion (HE) after intracerebral hemorrhage (ICH). We aimed to explore whether there were unreported laboratory biomarkers associated with HE that were readily and commonly available in clinical practice.

METHODS

We retrospectively analyzed consecutive acute ICH patients from 2012 to 2020 with admission laboratory tests and baseline and follow-up computed tomography (CT) scans. Univariate and multivariate regression analyses were used to evaluate associations between conventional laboratory indicators and HE. The results were verified in a prospective validation cohort. The relationship of candidate biomarker and 3-month outcomes was also investigated and mediation analysis was undertaken to determine causal associations among candidate biomarker, HE and outcome.

RESULTS

Of 734 ICH patients, 163 (22.2%) presented HE. Among the included laboratory indicators, higher direct bilirubin (DBil) was associated with HE (adjusted odds ratio [OR] of per 1.0 μmol/L change 1.082; 95% confidence interval [CI] 1.011-1.158). DBil >5.65 μmol/L was a predictor of HE in validation cohort. Higher DBil was also associated with poor 3-month outcomes. The mediation analysis indicated that the association of higher DBil and poor outcomes was partially mediated by HE.

CONCLUSIONS

DBil is a predictor of HE and poor 3-month outcomes after ICH. DBil's metabolic process and involvement in the pathological mechanism of HE are likely to contribute to the association between DBil and HE. Interventions targeting DBil to improve post-ICH prognosis may be meaningful and worthy of further exploration.

Ultrasound-guided percutaneous cholecystostomy as bridging or definitive treatment in patients with acute cholecystitis grade II or III

Background

We aimed to investigate the extent to which ultrasound (US)-guided percutaneous cholecystostomy (PC) is used as a bridging or definitive therapy for grade II and III acute cholecystitis and whether this treatment causes significant changes in C-reactive protein (CRP) and direct bilirubin (DB) levels in the first 72 h and the first three weeks.

Methods

We included 145 consecutive patients who underwent PC over 17 years. No patient had cirrhosis. PC was performed in the interventional radiology department under US guidance.

Results

US-guided PC was the definitive treatment for more than half of the patients (51.7%) and decreased DB levels significantly more than CRP levels.

Conclusion

No statistically significant correlation between those whose CRP and DB levels normalized within three weeks and those who did not and required a second invasive procedure. Nevertheless, the bridging treatment group was significantly older than the definitive treatment group.

Noninvasive direct bilirubin detection by spectral analysis of color images using a Mini-LED light source

Urine test paper is a standard, noninvasive detection method for direct bilirubin, but this method can only achieve qualitative analysis and cannot achieve quantitative analysis. This study used Mini-LEDs as the light source, and direct bilirubin was oxidized to biliverdin by an enzymatic method with ferric chloride (FeCl₃) for labeling. Images were captured with a smartphone and evaluated for red (R), green (G), and blue (B) colors to analyze the linear relationship between the spectral change of the test paper image and the direct bilirubin concentration. This method achieved noninvasive detection of bilirubin. The experimental results demonstrated that Mini-LEDs can be used as the light source to analyze the grayscale value of the image RGB. For the direct bilirubin concentration range of 0.1-2 mg/dL, the green channel had the highest coefficient of determination coefficient (R²) of 0.9313 and a limit of detection of 0.56 mg/dL. With this method, direct bilirubin concentrations higher than 1.86 mg/dL can be quantitatively analyzed with the advantage of rapid and noninvasive detection.

Using Blue Mini-LEDs as a Light Source Designed a Miniaturized Optomechanical Device for the Detection of Direct Bilirubin

This study developed a miniaturized optomechanical device (MOD) for the feasibility study of direct bilirubin in urine using high-collimation blue mini-light-emitting diodes (Mini-LEDs) as the light source. The constructed MOD used optical spectroscopy to analyze different concentrations of direct bilirubin using the absorbance spectrum to achieve a noninvasive method for detection. The experimental results showed that between the absorbance and different concentrations of direct bilirubin at the blue Mini-LEDs central wavelength (462 nm) was the optimum fitting wavelength; in the direct bilirubin concentration range from 0.855 to 17.1 μmol/L, the coefficient of determination (R²) was 0.9999, the limit of detection (LOD) of 0.171 μmol/L, and the limit of quantitation (LOQ) of 0.570 μmol/L. Therefore, we propose using blue Mini-LEDs as a light source to design a MOD to replace the invasive blood sampling method with a spectroscopic detection of direct bilirubin concentration corresponding to absorbance.

Surface plasmon-enhanced fluorescence and surface-enhanced Raman scattering dual-readout chip constructed with silver nanowires: Label-free clinical detection of direct-bilirubin

It has been found that the direct/total bilirubin ratio (D/T-BIL) is related to the survival rate of COVID-19 pneumonia. The presence of an excessive amount of bilirubin in human blood also causes liver and neurological damage, leading to death. Therefore, upon considering the adverse impact of the presence of excessive bilirubin in human blood, it has become highly imperative to detect bilirubin in a fast and label-free manner. Herein, we designed and constructed a random-crossed-woodpile nanostructure from silver nanowires to form a 3-dimensional plasmonic hotspot-rich (3D-PHS) nanostructure and successfully used it to detect direct bilirubin (D-BIL) in human blood in a label-free manner. The 3D-PHS nanochip provides rich spatial hot spots that are simultaneously responsive to SERS and SPEF effects and consequently, successfully used to measure and characterize D-BIL with a detection limit of ∼10 nM, requiring only 10μL of human serum for rapid screening, which is the first time D-BIL has been detected in a clinically relevant range. This demonstrates a simple, label-free, pretreatment-free potential biosensing technology that can be used in health care units, and further, in the efficient detection of point-of-care testing with a portable spectrometer.

Elevated serum bilirubin may significantly reduce coronary heart disease risk in females: A prospective cohort study

BACKGROUND AND AIMS

There is still inconsistent evidence over the protective effect of total bilirubin on the development of coronary heart disease (CHD). Therefore, we aimed to investigate the association between bilirubin in population subtypes and the risks of CHD between different gender and menstruation subgroups.

METHODS AND RESULTS

In this prospective cohort study, 29,750 participants free of CHD with an average age of 47 ± 14 years were recruited at baseline; of these, 720 CHD first-attack cases were collected after 7-years of follow up. The covariate-adjusted Cox proportional hazards models were used to estimate hazard ratios (HRs) of CHD with 95% confidence intervals (CIs). The serum bilirubin concentration was quarterly stratified based on the distribution of healthy population without CHD onset. The HRs of incident CHD decreased with elevated bilirubin in females (ρ trend<0.05), but not males. In postmenopausal females, compared with the lowest quartile of total bilirubin, the adjusted HRs for the third and fourth quartiles were 0.64 (95% CI: 0.45, 0.93) and 0.59 (95% CI: 0.42, 0.86), the adjusted HRs in the third and fourth quartiles of direct bilirubin were 0.56 (0.39, 0.82) and 0.56 (0.38, 0.81), and for indirect bilirubin, corresponding HR in the highest quartile was 0.56 (0.38, 0.83).

CONCLUSION

Elevated serum bilirubin was inversely associated with adjusted HRs of CHD in females, especially postmenopausal females. The relationship between elevated direct bilirubin and reduced HRs of CHD may be closer than indirect bilirubin in postmenopausal females.

Newborn Screening for Biliary Atresia: a Review of Current Methods

PURPOSE OF REVIEW

Biliary atresia is a serious neonatal liver disease due to obstructed bile ducts that has better outcomes when detected and treated in the first 30-45 days of life. This review examines different methods to screen newborns for biliary atresia as well as discusses observations from ongoing screening programs implemented in parts of the United States.

RECENT FINDINGS

Screening strategies for biliary atresia include detecting persistent jaundice, examining stool color, testing fractionated bilirubin levels, or measuring bile acid levels from dried blood spot cards. The stool color card program is the most widely used screening strategy worldwide. An alternative approach under investigation in the United States measures fractionated bilirubin levels, which are abnormal in newborns with biliary atresia. Fractionated bilirubin screening programs require laboratories to derive reference ranges, nurseries to implement universal testing, and healthcare systems to develop infrastructure that identifies and acts upon abnormal results. Biliary atresia meets the disease-specific criteria for newborn screening. Current studies focus on developing a strategy which also meets all test-specific criteria. Such a strategy, if implemented uniformly, has the potential to accelerate treatment and reduce biliary atresia's large liver transplant burden.

Bile Acids, Direct Bilirubin and Gamma-glutamyltransferase as Prognostic Indicators for Horses with Liver Disease in the Eastern United States: 82 Cases (1997-2019)

Serum biochemistry results and presence of fibrosis on liver biopsies are frequently used as prognostic indicators in horses with liver dysfunction. The objective of this retrospective multicenter study was to determine if the magnitude of abnormal liver specific biochemical tests such as bile acids (BA), direct bilirubin and gamma-glutamyltransferase (GGT), or the presence of fibrosis reported on liver biopsies was associated with prognosis in horses with liver dysfunction. Eighty-two horses older than one year, examined at four referral hospitals in the eastern United States, with BA values greater than 30 µmol/L and having 6-months or more follow-up were included in the study. The association of the maximal BA, GGT and direct bilirubin values of each horse with survival was determined by logistic regression analysis. The presence or absence of fibrosis (non-quantitated) on a liver biopsy was compared between survivors and non-survivors by chi square test. The degree of increase in BA concentration and GGT activity was not related to outcome (OR 0.9999, 95% CI 0.9923 - 1.007, P = 0.97, and OR 1.0, 95% CI 0.9997 - 1.001, P = 0.31 respectively). Direct bilirubin concentration was positively associated with non-survival (OR 1.95, 95% CI 1.34-3.19, P = 0.0023). The presence of fibrosis was not associated with outcome (P = 0.37). These findings suggest that the magnitude of GGT and BA values or the mere presence of fibrosis on liver histopathology should not be used as prognostic indicators. In this study, direct bilirubin values were a better predictor of outcome.

Direct Bilirubin in Drainage Fluid 3 days after Hepatectomy Is Useful for Detecting Severe Bile Leakage

INTRODUCTION

The International Study Group of Liver Surgery (ISGLS) definition of bile leakage is an elevated total bilirubin concentration in the drainage fluid after post-operative day (POD) 3, which has been widely accepted. However, there were no reports about direct bilirubin in drainage fluid to predict bile leakage.

METHODS

Data from 257 patients who underwent hepatectomy were retrospectively reviewed. The optimal cut-off value was investigated using receiver-operating characteristic curves. The predictive power of drainage fluid total bilirubin (dTB) and drainage fluid direct bilirubin (dDB) to predict bile leakage, which was defined using ISGLS grade B or grade C, were compared.

RESULTS

ISGLS grade B bile leakage occurred in 16 patients (6.2%). Area under the curve (AUC) of dDB was always higher than that of dTB on each POD. The AUC of dDB was >0.75 on PODs 2, 3, and 5, and then it increased with the increasing POD. The dDB on POD 5 showed the highest accuracy (0.91) and positive predictive value (PPV) (0.67), which was followed by dTB/serum total bilirubin (sTB) on POD 3 (accuracy, 0.91; PPV, 0.33). Because the PPV of dDB increased as the POD increased, dDB was better than dTB for predicting clinically significant bile leakage. dDB on POD 3 showed the highest negative predictive value (0.97). The positive likelihood of dDB increased and the negative likelihood of dDB decreased on the basis of the POD. Among patients with dTB/sTB ≤3 on POD 3, 19.1% of these patients had bile leakage when dDB was >0.44 on POD 3.

CONCLUSIONS

Measurement of both dDB and dTB, which are easy to perform, can be used to effectively predict clinically significant bile leakage.

Direct Bilirubin Is More Valuable than Total Bilirubin for Predicting Prognosis in Patients with Liver Cirrhosis

Background/Aims

Most prognostic prediction models for patients with liver cirrhosis include serum total bilirubin (TB) level as a component. This study investigated prognostic performance of serum direct bilirubin (DB) and developed new DB level-based prediction models for cirrhosis.

Methods

A total of 983 hospitalized patients with liver cirrhosis were included. DB-Model for End-Stage Liver Disease (MELD) score was calculated using MELD score formula, with serum DB level replacing TB level.

Results

Mean age of study population was 56.1 years. Alcoholic liver disease was the most frequent underlying condition (471 patients, 47.9%). Within 6 months, 144 patients (14.6%) died or received liver transplantation due to severe liver dysfunction. The area under the receiver operating characteristic curve (AUROC) for prediction of 6-month mortality with DB level was significantly higher than that with TB level (p<0.001). The AUROC of DB-MELD score for prediction of 6-month mortality was significantly higher than that of MELD score (p<0.001). Patients were randomly divided into training (n=492) and validation (n=491) cohorts. A new prognostic prediction model, “Direct Bilirubin, INR, and Creatinine” (DiBIC) score, was developed based on the most significant predictors of 6-month mortality. In training set, AUROC of DiBIC score for prediction of 6-month mortality was 0.892, which was significantly higher than that of the MELD score (0.875, p=0.017), but not different from that of DB-MELD score (0.886, p=0.272). Similar results were observed in validation set.

Conclusions

New prognostic models, DB-MELD and DiBIC scores, have good prognostic performance in liver cirrhosis patients, outperforming other currently available models.

Insomnia affects the levels of plasma bilirubin and protein metabolism: an observational study and GWGEIS in UK Biobank cohort

STUDY OBJECTIVES

We aim to explore the mechanism of relationship between insomnia and liver metabolism by examining the gene × insomnia interactions.

METHODS

Individual level genotypic and phenotypic data were obtained from the UK Biobank cohort. Regression analysis was first conducted to test the association of insomnia with plasma total bilirubin (TBil; n = 186,793), direct bilirubin (DBil; n = 159,854) and total protein (TP; n = 171,574) in UK Biobank cohort. Second, genome-wide gene-environment interaction study (GWGEIS) was conducted by PLINK 2.0, and FUMA platform was used to identify enriched pathway terms.

RESULTS

In UK Biobank cohort, we found that TP (P < 2.00 × 10^-16), DBil (P = 1.72 × 10^-3) and TBil (P = 3.38 × 10^-5) were significantly associated with insomnia. GWGEIS of both DBil and TBil observed significant G × INSOMNIA effects between insomnia and UDP Glucuronosyltransferase Family 1 (rs6431558, P = 6.26 × 10^-11) gene. GWGEIS of TP also detected several significant genes interacting with insomnia, such as KLF15, (rs70940816, P = 6.77 × 10^-10) and DOK7, (rs2344205, P = 1.37 × 10^-9). Multiple gene ontology (GO) terms were identified for bilirubin, such as GO_URONIC_ACID_METABOLIC_PROCESS (adjusted P = 4.15 × 10^-26).

CONCLUSION

Our study results suggested negative associations between insomnia and DBil and TBil; and a positive association between insomnia and TP.

Association of liver abnormalities with in-hospital mortality in patients with COVID-19

BACKGROUND & AIMS

The evolution and clinical significance of abnormal liver chemistries and the impact of hepatitis B infection on outcome in patients with COVID-19 is not well characterized. This study aimed to explore these issues.

METHODS

This large retrospective cohort study included 2,073 patients with coronavirus disease 2019 (COVID-19) and definite outcomes in Wuhan, China. Longitudinal liver function tests were conducted, with associated factors and risk of death determined by multivariate regression analyses. A prognostic nomogram was formulated to predict the survival of patients with COVID-19. The characteristics of liver abnormalities and outcomes of patients with COVID-19, with and without hepatitis B, were compared after 1:3 propensity score matching.

RESULTS

Of the 2,073 patients, 1,282 (61.8%) had abnormal liver chemistries during hospitalization, and 297 (14.3%) had a liver injury. The mean levels of aspartate aminotransferase (AST) and direct bilirubin (D-Bil) increased early after symptom onset in deceased patients and showed disparity compared to levels in discharged patients throughout the clinical course of the disease. Abnormal AST (adjusted hazard ratio [HR] 1.39; 95% CI 1.04-1.86, p = 0.027) and D-Bil (adjusted HR 1.66; 95% CI 1.22-2.26; p = 0.001) levels at admission were independent risk factors for mortality due to COVID-19. A nomogram was established based on the results of multivariate analysis and showed sufficient discriminatory power and good consistency between the prediction and the observation. HBV infection in patients did not increase the risk of poor COVID-19-associated outcomes.

CONCLUSIONS

Abnormal AST and D-Bil levels at admission were independent predictors of COVID-19-related mortality. Therefore, monitoring liver chemistries, especially AST and D-Bil levels, is necessary in hospitalized patients with COVID-19.

LAY SUMMARY

Liver test abnormalities (in particular elevations in the levels of aspartate aminotransferase [AST] and direct bilirubin [D-Bil]) were observed after symptom onset in patients who went on to die of coronavirus disease 2019 (COVID-19). Abnormal levels of AST and D-Bil at admission were independent predictors of COVID-19-related mortality. HBV infection in patients did not increase the risk of poor COVID-19-associated outcomes.

An effective enzymatic assay for pH selectively measuring direct and total bilirubin concentration by using of CotA

In this study, we aimed to develop B. subtilis spore coat protein A (CotA) for the enzymatic determination of bilirubin. Firstly, molecular docking and oxidation kinetic analysis confirmed the feasibility of CotA for oxidizing bilirubin. Secondly, CotA showed pH-preferable oxidization performance to direct bilirubin (DB) in acidic conditions and an alkaline-catalytic oxidation capacity to total bilirubin (TB). Mechanism analysis results confirm that the conformational changes of CotA, DB and UB caused by pH changes are responsible for the selective oxidation of DB and TB by CotA. Then, CotA exhibits better structural characteristics and enzymatic performance than M. verrucaria-derived bilirubin oxidase (Mv-BOD). Besides, the strong anti-interference ability helps CotA adapt to complex catalytic environment in the detection of DB and TB. Our results prove that CotA can be used as a promising candidate bio-enzymatic detection reagent for DB and TB.

A nomogram based on pretreatment levels of serum bilirubin and total bile acid levels predicts survival in colorectal cancer patients

Background

Serum bilirubin and total bile acid (TBA) levels have been reported to be strongly associated with the risk and prognosis of certain cancers. Here, we aimed to investigate the effects of pretreatment levels of serum bilirubin and bile acids on the prognosis of patients with colorectal cancer (CRC).

Methods

A retrospective cohort of 1474 patients with CRC who underwent surgical resection between January 2015 and December 2017 was included in the study. Survival analysis was used to evaluate the predictive value of pretreatment levels of bilirubin and bile acids. X-Tile software was used to identify optimal cut-off values for total bilirubin (TBIL), direct bilirubin (DBIL) and TBA in terms of overall survival (OS) and disease-free survival (DFS).

Results

DBIL, TBIL, and TBA were validated as significant prognostic factors by univariate Cox regression analysis for both 3-year OS and DFS. Multivariate Cox regression analyses confirmed that high DBIL, TBIL and TBA levels were independent prognostic factors for both OS (HR: 0.435, 95% CI: 0.299–0.637, P < 0.001; HR: 0.436, 95% CI: 0.329–0.578, P < 0.001; HR: 0.206, 95% CI: 0.124–0.341, P < 0.001, respectively) and DFS (HR: 0.583, 95% CI: 0.391–0.871, P = 0.008; HR:0.437,95% CI: 0.292–0.655, P <0.001; HR: 0.634, 95% CI: 0.465–0.865, P = 0.004, respectively). In addition, nomograms for OS and DFS were established according to all significant factors, and the c-indexes were 0.819 (95% CI: 0.806–0.832) and 0.835 (95% CI: 0.822–0.849), respectively.

Conclusions

TBIL, DBIL and TBA levels are independent prognostic factors in colorectal cancer patients. The nomograms based on OS and DFS can be used as a practical model for evaluating the prognosis of CRC patients.

[C-reactive protein and direct bilirubin as the early diagnostic indicators of primary hepatocellular carcinoma combined with macrovascular invasion]

Objective: To explore the early clinical diagnostic indicators in patients with primary hepatocellular carcinoma (HCC) combined with macrovascular invasion. Methods: The clinical data of 180 cases of HCC diagnosed by histopathology examination in the Second Affiliated Hospital of Chongqing Medical University from 2012 to 2019 were retrospectively analyzed. The factors influencing the development of macrovascular invasion in HCC patients were analyzed. The receiver operating characteristic curve (ROC curve) was used to evaluate the sensitivity and specificity. Results: Serum C-reactive protein (CRP) level was significantly correlated with various clinical characteristics of HCC patients, including the maximum tumor diameter, tumor number, and macrovascular invasion. Further analysis of the risk factors showed that serum direct bilirubin and CRP were independent risk factors for macrovascular invasion in HCC patients, with odds ratios of 1.747 (95% CI 1.119-2.728, P = 0.014) and 2.376 (95% CI 1.495-3.775, P < 0.001). ROC curve analysis showed that serum CRP, direct bilirubin, and the combination of the both had certain diagnostic value for hepatocellular carcinoma combined with macrovascular invasion. The area under the curve, sensitivity and specificity was 0.724, 0.668, 0.743, 79.1%, 70.1%, 79.1%, and 61.9%, 62.8%, 67.3%, respectively. Conclusion: The combination of CRP with direct bilirubin can be used as an important clinical diagnostic indicator for early diagnosis and prevention of hepatocellular carcinoma combined with macrovascular invasion.

Rapid and simultaneous analysis of direct and indirect bilirubin indicators in serum through reagent-free visible-near-infrared spectroscopy combined with chemometrics

Indirect (IBil), direct (DBil) and total (TBil) bilirubin are important clinical indicators of hepatobiliary diseases, which require rapid detection in diagnosis and treatment. IBil and DBil have a structural relationship with several macromolecules in hepatobiliary metabolism. Here, the rapid analysis models for bilirubin indicators using serum visible-near-infrared (Vis-NIR) spectroscopy were established. Norris derivative filter with optimisation was used for spectral pretreatment; the optimal parameters (derivative order, number of smoothing points, number of differential gaps) were (2, 15, 9) for IBil; (2, 13, 9) for DBil, respectively. Equidistant combination-partial least squares (EC-PLS) was used for large-scale wavelength screening. Wavelength step-by-step phase-out PLS (WSP-PLS) was used for secondary wavelength optimisation. The wavelength models of the optimal EC-WSP-PLS for IBil and DBil included 11 and 18 wavelengths, respectively. In independent validation, the root-mean-square errors and correlation coefficient for prediction (SEP, R_P), and ratio of performance-to-deviation (RPD) were 0.90 μmol L^-1, 0.975, and 4.4 for IBil; 0.71 μmol L^-1, 0.955, and 3.3 for DBil, respectively. TBil was subjected to spectral analysis, and the summation of the prediction values of IBil and DBil was compared. The latter was obviously better, and SEP, R_P, RPD were 0.82 μmol L^-1, 0.990, 7.1, respectively. The results for IBil, DBil and TBil indicated high correlation, low error and good overall prediction ability and confirmed the feasibility of the simultaneous analysis of bilirubin indicators through reagent-free serum Vis-NIR spectroscopy. The proposed method is crucial for the rapid screening of large populations and the treatment of hepatobiliary diseases.

Test Utilization Proposal for Reflex Bilirubin Testing: Why Order Two Tests When One Will Do?

BACKGROUND

Reflex testing algorithms are effective tools to reduce unnecessary laboratory testing. Direct (conjugated) bilirubin (DB) and total bilirubin (TB) are often ordered together at our institution. Therefore, the objective of our study was to evaluate the potential impact of performing reflex testing for DB when TB is elevated.

METHODS

We performed a retrospective review of test orders (patients ≥18 years of age) for DB, TB, or for both DB and TB on the same accession number received in our stat laboratory from January through April 2017. The orders were binned into 4 categories depending on the results from each individual test: (a) DB normal and TB normal, (b) DB normal and TB high, (c) DB high and TB normal, and (d) DB high and TB high. The percentage of orders and median (range) test result for each category was calculated.

RESULTS

During the months evaluated, a total of 4828 stat orders were placed for DB, TB, or both DB and TB. A total of 4296 stat orders (89%) were placed with both DB and TB on the same accession number for 4158 unique patients. Of those orders, the vast majority of tests (87.3%) contained normal results for both analytes; only 12.7% of orders contained ≥1 abnormal result.

CONCLUSIONS

The majority of all bilirubin tests ordered stat for emergency department and hospitalized patients have values within the reference interval. Consequently, if reflex testing were executed on elevated TB, a large number of DB tests could be avoided.

Direct bilirubin is associated with low-density lipoprotein subfractions and particle size in overweight and centrally obese women

BACKGROUND AND AIMS

Bilirubin has antioxidant and anti-inflammatory properties; serum bilirubin levels have been known to be inversely associated with cardiovascular disease. However, the effects of different bilirubin subtypes on cardiometabolic traits are unknown. In this study, we aimed to determine whether direct bilirubin is more strongly correlated with small, dense low-density lipoprotein (sdLDL) compared to other bilirubin subtypes. We also investigated which LDL subfractions exhibited the highest correlation with direct bilirubin.

METHODS AND RESULTS

A total of 288 overweight and centrally obese women were included in this study. The Pearson correlation and Steiger's Z test were used to compare the correlation coefficients between bilirubin subtypes and lipoproteins. Multiple linear regression analyses were used to evaluate the independent association between direct bilirubin and mean LDL particle size. Only direct bilirubin levels were significantly associated with the sdLDL subfraction and mean LDL particle size. Mean LDL particle size exhibited a significantly stronger correlation with direct bilirubin than sdLDL, percent sdLDL, and the sdLDL:large LDL ratio. Regression analysis showed that direct bilirubin was significantly associated with mean LDL particle size, according to both the stepwise method (β = 11.445, P value = 0.002) and the enter method (β = 11.655, P value = 0.002).

CONCLUSIONS

Direct bilirubin is more strongly correlated with the sdLDL subfraction compared with total and indirect bilirubin, and is independently associated with mean LDL particle size in overweight and centrally obese women.

Prognostic value of serum bilirubin in southern Chinese patients with advanced nasopharyngeal carcinoma

BACKGROUND

We evaluated the prognostic value of serum bilirubin in advanced nasopharyngeal carcinoma (NPC) patients.

METHODS

Seven-hundred fifty-nine advanced NPC patients treated with definitive chemoradiotherapy were retrospectively analyzed. Serum indirect bilirubin (IBIL) and direct bilirubin (DBIL) were measured before treatment. To evaluate different cutoff points for serum bilirubin, we utilized ROC curves. The Kaplan-Meier method and log-rank test were adopted to calculate and compare survival outcomes. Cox proportional hazard models were used to perform univariate and multivariate analyses.

RESULTS

At 5 y, IBIL >7.15 μmol/l were significantly associated with superior progression-free survival (PFS, 83.6% vs 70.3%; P < .001), overall survival (OS, 88.6% vs 80.5%; P = .012), distant metastasis-free survival (DMFS, 90.3% vs 82.8%; P = .006), and locoregional relapse-free survival (LRFS, 92.1% vs 86.4%; P = .048) than IBIL ≤7.15 μmol/l. Similarly, patients with DBIL >2.65 μmol/l had better prognosis across all outcomes than those of patients with DBIL ≤2.65 μmol/l (all P < .05), except no difference was observed in LRFS (90.5% vs. 87.3%, P = .195). Multivariate analyses showed that IBIL >7.15 μmol/l was an independent protective prognostic factor for PFS (HR, 0.57; 95% CI, 0.40-0.81; P = .002), OS (HR, 0.67; 95% CI, 0.43-0.92; P = .041), and DMFS (HR, 0.63; 95% CI, 0.40-0.98; P = .034); while serum DBIL only remained significant for PFS (HR, 0.63; 95% CI, 0.44-0.89; P = .009).

CONCLUSIONS

Pretreatment IBIL and DBIL are potentially independent prognostic factors for patients with advanced NPC.

Screening for biliary atresia

Early diagnosis followed by proper KP is essential for the improvement of long-term prognosis for patients with BA. It is increasingly accepted that KP at ≤ 30 days of age significantly improves native liver survival rate. Published analyses in English and Japanese indicate that screening by SCC and DB/CB is potentially feasible. Screening with SCC has been implemented in Tochigi Prefecture, Japan, since 1994. The concept of SCC was introduced from Japan to Taiwan and resulted in nationwide screening with SCC for the first time in Taiwan in 2004, followed by Japan in 2012. Home-based screening using SCC is easy and cost-effective; however, it may cause some difficulties for families in case of stools with intermediate colors. Laboratory-based screening using DB/CB may detect the suspected cases earlier, resulting in an increase in the number of patients with BA who undergo KP at ≤ 30 days of age; however, the recall rate is 1% and may be beyond an acceptable range. Further studies are needed to assess the feasibility and cost-effectiveness of both home-based (SCC) and laboratory-based (DB/CB) screening for BA.

Higher direct bilirubin levels during mid-pregnancy are associated with lower risk of gestational diabetes mellitus

Bilirubin concentrations have been recently reported to be negatively associated with type 2 diabetes mellitus. We examined the association between bilirubin concentrations and gestational diabetes mellitus. In a prospective cohort study, 2969 pregnant women were recruited prior to 16 weeks of gestation and were followed up until delivery. The value of bilirubin was tested and oral glucose tolerance test was conducted to screen gestational diabetes mellitus. The relationship between serum bilirubin concentration and gestational weeks was studied by two-piecewise linear regression. A subsample of 1135 participants with serum bilirubin test during 16-18 weeks gestation was conducted to research the association between serum bilirubin levels and risk of gestational diabetes mellitus by logistic regression. Gestational diabetes mellitus developed in 8.5 % of the participants (223 of 2969). Two-piecewise linear regression analyses demonstrated that the levels of bilirubin decreased with gestational week up to the turning point 23 and after that point, levels of bilirubin were increased slightly. In multiple logistic regression analysis, the relative risk of developing gestational diabetes mellitus was lower in the highest tertile of direct bilirubin than that in the lowest tertile (RR 0.60; 95 % CI, 0.35-0.89). The results suggested that women with higher serum direct bilirubin levels during the second trimester of pregnancy have lower risk for development of gestational diabetes mellitus.

Direct bilirubin in clinical practice - Interpretation and haemolysis interference guidance reassessed

OBJECTIVE

Diagnosis of hyperbilirubinaemia may rely on direct bilirubin (DBIL) measurement. Specimen suitability for DBIL depends on the degree of haemolysis present and method specifications. Our study reassesses the empiric, syncretised haemolysis guidance for DBIL measurement.

METHODS

Diazo and vanadate-oxidation assays for DBIL are compared, using sera from adults and neonates. Subsequent data analyses and statistics guide our conclusions on the clinical utility of haemolysed sera.

RESULTS

48% Patients' specimens had haemolysis exceeding the diazo-DBIL assay's specified haemolysis limit, thus generating 'specimen unsuitable' comment on clinical reports. Our linearity study shows a diazo-DBIL bias of up to 21μmol/L in diluted specimens, regardless of grade of haemolysis. Haemolysed patients' serum gives unpredictably biased diazo-DBIL results relative to results from vanadate-oxidation method. The pleiotropy of effect includes negative, negligible, and positive bias; a greater bias is apparent when albumin is <37g/L. Predominant unconjugated hyperbilirubinaemia is defined as the 90th percentile D/TBIL limit of <36%, mixed hyperbilirubinaemia by D/TBIL 36-60%, and mainly conjugated hyperbilirubinaemia when D/TBIL is >60%.

CONCLUSIONS

Haemolysed diazo-DBIL result is unsuitable for clinical use, due to unpredictability of observed bias. Our data shows that current haemolysis guidance is inaccurate and in need of revision. There is no direct association between haemolysis and diazo-DBIL results. Notwithstanding haemolysis, type of assay, and low albumin concentration, our study show D/TBIL% facilitates detection of the nature of hyperbilirubinaemia present. In addition, laboratories have an option to select a more befitting assay, such as the vanadate-oxidation method as it is unaffected by haemolysis.

Significance and prognostic value of increased serum direct bilirubin level for lymph node metastasis in Chinese rectal cancer patients

AIM: To determine the significance of increased serum direct bilirubin level for lymph node metastasis (LNM) in Chinese rectal cancer patients, after those with known hepatobiliary and pancreatic diseases were excluded.

METHODS: A cohort of 469 patients, who were treated at the China-Japan Friendship Hospital, Ministry of Health (Beijing, China), in the period from January 2003 to June 2011, and with a pathological diagnosis of rectal adenocarcinoma, were recruited. They included 231 patients with LNM (49.3%) and 238 patients without LNM. Follow-up for these patients was taken through to December 31, 2012.

RESULTS: The baseline serum direct bilirubin concentration was (median/inter-quartile range) 2.30/1.60-3.42 μmol/L. Univariate analysis showed that compared with patients without LNM, the patients with LNM had an increased level of direct bilirubin (2.50/1.70-3.42 vs 2.10/1.40-3.42, P = 0.025). Multivariate analysis showed that direct bilirubin was independently associated with LNM (OR = 1.602; 95%CI: 1.098-2.338, P = 0.015). Moreover, we found that: (1) serum direct bilirubin differs between male and female patients; a higher concentration was associated with poor tumor classification; (2) as the baseline serum direct bilirubin concentration increased, the percentage of patients with LNM increased; and (3) serum direct bilirubin was associated with the prognosis of rectal cancer patients and higher values indicated poor prognosis.

CONCLUSION: Higher serum direct bilirubin concentration was associated with the increased risk of LNM and poor prognosis in our rectal cancers.

Hepatoprotective activity of Musa paradisiaca on experimental animal models

OBJECTIVE

To investigate the hepatoprotective activity of stem of Musa paradisiaca (M. paradisiaca) in CCl4 and paracetamol induced hepatotoxicity models in rats.

METHODS

Hepatoprotective activity of alcoholic and aqueous extracts of stem of M. paradisiaca was demonstrated by using two experimentally induced hepatotoxicity models.

RESULTS

Administration of hepatotoxins (CCl4 and paracetamol) showed significant biochemical and histological deteriorations in the liver of experimental animals. Pretreatment with alcoholic extract (500 mg/kg), more significantly and to a lesser extent the alcoholic extract (250 mg/kg) and aqueous extract (500 mg/kg), reduced the elevated levels of the serum enzymes like serum glutamic-oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT), alkaline phosphatase (ALP) and bilirubin levels and alcoholic and aqueous extracts reversed the hepatic damage towards the normal, which further evidenced the hepatoprotective activity of stem of M. paradisiaca.

CONCLUSIONS

The alcoholic extract at doses of 250 and 500 mg/kg, p.o. and aqueous extract at a dose of 500 mg/kg, p.o. of stem of M. paradisiaca have significant effect on the liver of CCl4 and paracetamol induced hepatotoxicity animal models.

The most reliable early predictors of outcome in patients with biliary atresia after Kasai's operation

BACKGROUND/PURPOSE

The purpose of this study was to determine reliable predictors of outcome of biliary atresia (BA) after Kasai's operation.

PATIENTS AND METHODS

Fifty-four BA cases that underwent Kasai's operation at our institution over two decades were reviewed. The cases were divided into two groups: Group I: cases that required liver transplantation or died (n=30) and Group II: cases alive with the native liver. Serum levels of total bilirubin (TB), direct bilirubin (DB), aspartate aminotransferase (AST), alanine aminotransferase (ALT), and gamma-glutamyltransferase (GGT) were measured sequentially after surgery. For cut-off determination, receiver operating characteristic (ROC) analysis was employed.

RESULTS

Serum TB, DB, AST, and ALT in Group I were significantly higher than those in Group II at 1, 2, and 3 months after surgery (p<.05). The most reliable cut-offs determined by ROC analysis were DB of 0.7 mg/dl at 2 months (sensitivity; 93%, specificity; 75%) and AST of 94 IU/L at 2 months (sensitivity; 87%, specificity; 71%). The 54 cases were re-divided into three groups according to the cut-off values: group G (good) with DB and AST<cut-offs (n=16; Group I:II=1:15), group M (moderate) with DB or AST>cut-offs (n=9; Group I:II=4:5), and group P (poor) with DB and AST ≥ cut-offs (n=29; Group I:II=25:4). The 15-year survival rate in groups G, M, and P was 94%, 44%, and 22%, respectively (p<.001).

CONCLUSION

The combination of serum DB and AST at 2 months after Kasai's operation is a reliable predictor of long-term BA outcome.

Changes in the balance between Treg and Th17 cells in patients with chronic hepatitis B

The purpose of this study was to explore the role of Treg cells, Th17 cells and cytokines associated with Treg/Th17 differentiation in the occurrence, development and outcome of chronic hepatitis B (CHB). To do so, we detected populations of Treg and Th17 cells and their associated cytokines in the peripheral blood of CHB patients. The populations of Treg cells (CD4(+)CD25(high)CD127(low) T cells) and Th17 cells (CD3(+)CD8(-)IL-17(+) T cells) were analyzed in 46 patients with low to moderate chronic hepatitis B (CHB-LM), 24 patients with severe chronic hepatitis B (CHB-S) and 20 healthy controls (HC) using flow cytometry. The levels of cytokines associated with Treg/Th17 differentiation, including IL-10, TGF-β1, IL-17 and IL-23, were measured by enzyme-linked immunosorbent assay (ELISA). Our study showed that the imbalance of Treg and Th17 cells might play an important role in the occurrence, development and outcome of CHB.