Risk of acute liver injury following the nirmatrelvir/ritonavir use

BACKGROUND

Elevations in alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were reported as adverse events of nirmatrelvir/ritonavir users in the EPIC-HR trial.

AIM

To quantify the risk and severity of acute liver injury (ALI) associated with nirmatrelvir/ritonavir use.

METHODS

This self-controlled case-series study was conducted using electronic medical records of patients with confirmed diagnosis of SARS-CoV-2 infection between 26th February 2022 and 12th February 2023 in Hong Kong.

RESULTS

Among 2 409 848 patients with SARS-CoV-2 infection during the study period, 153 853 were prescribed with nirmatrelvir/ritonavir, of whom 834 (.5%) had incident ALI (moderate: 30.5%; moderate to severe: 18.9%; severe or fatal: 5.8%). Compared with the non-exposure period, risk of ALI increased significantly during the pre-exposure period (IRR = 38.13, 95% CI = 29.29-49.62) and remained elevated during the five-day nirmatrelvir/ritonavir treatment (IRR = 20.75, 95% CI = 17.06-25.25) and during wash-out period (IRR = 16.27, 95% CI = 13.23-20.01). Compared to the pre-exposure period, risk of ALI was not increased during the five-day nirmatrelvir/ritonavir treatment period (IRR = .54, 95% CI = .43-.70). Compared to 5469 non-nirmatrelvir/ritonavir users with incident ALI, nirmatrelvir/ritonavir users had less severe ALI by the severity index (p < .001) and peak INR (1.7 vs. 2.3; p < .001). ALI cases with nirmatrelvir/ritonavir use had lower risk of all-cause death (29.1% vs. 39.1%; OR = .64; p < .001) and no increase in risk of liver decompensation (1.0% vs. 1.3%; OR = .62; p = .230) compared to non-users.

CONCLUSION

The risk of ALI associated with nirmatrelvir/ritonavir treatment for COVID-19 was elevated in the pre-exposure period, but not following nirmatrelvir/ritonavir initiation. ALI following nirmatrelvir/ritonavir treatment were mostly mild and less severe than ALI events in non-nirmatrelvir/ritonavir users.

Risk of acute liver injury following the mRNA (BNT162b2) and inactivated (CoronaVac) COVID-19 vaccines

BACKGROUND & AIMS

Case reports of severe acute liver injury (ALI) following COVID-19 vaccination have recently been published. We evaluated the risks of ALI following COVID-19 vaccination (BNT162b2 or CoronaVac).

METHODS

We conducted a modified self-controlled case series analysis using the vaccination records in Hong Kong with data linkage to electronic medical records from a territory-wide healthcare database. Incidence rate ratios (IRRs) for ALI outcome in the 56-day period following first and second doses of COVID-19 vaccines in comparison to the non-exposure period were estimated and compared to the ALI risk in patients with SARS-CoV-2 infection.

RESULTS

Among 2,343,288 COVID-19 vaccine recipients who were at risk, 4,677 patients developed ALI for the first time between 23^rd February 2021 to 30^th September 2021. The number of ALI cases within 56 days after the first and second dose of vaccination were 307 and 521 (335 and 334 per 100,000 person-years) for BNT162b2, and 304 and 474 (358 and 403 per 100,000 person-years) for CoronaVac, respectively, compared to 32,997 ALI cases per 100,000 person-years among patients within 56 days of SARS-CoV-2 infection. Compared to the non-exposure period, no increased risk was observed in the 56-day risk period for first (IRR 0.800; 95% CI 0.680-0.942) and second (IRR 0.944; 95% CI 0.816-1.091) dose of BNT162b2, or first (IRR 0.689; 95% CI 0.588-0.807) and second (IRR 0.905; 95% CI 0.781-1.048) dose of CoronaVac. There were no severe or fatal cases of ALI following COVID-19 vaccination.

CONCLUSION

There was no evidence of an increased risk of ALI associated with BNT162b2 or CoronaVac vaccination. Based on all current available evidence from previous studies and our study, the benefit of mass vaccination far outweighs the ALI risk from vaccination.

LAY SUMMARY

There have been some recent reports that COVID-19 vaccination could be associated with acute liver injury. In our study, we found no evidence that COVID-19 vaccination increased the risk of acute liver injury, which was much more common after SARS-CoV-2 infection than after vaccination. Hence, our study provides further data indicating that the benefits of mass COVID-19 vaccination outweigh the potential risks.

Remdesivir use and risks of acute kidney injury and acute liver injury among patients hospitalised with COVID-19: a self-controlled case series study

BACKGROUND AND AIM

To investigate and quantify the risks of AKI and ALI associated with remdesivir use, given the underlying diseases of SARS-CoV-2 infection.

METHODS

This self-controlled case series (SCCS) study was conducted using electronic hospital records between 23 January 2020 and 31 January 2021 as retrieved from the Hong Kong Hospital Authority which manages all laboratory-confirmed COVID-19 cases in Hong Kong. Outcomes of AKI and ALI were defined using the KDIGO Guideline and Asia Pacific Association of Study of Liver consensus guidelines. Incidence rate ratios (IRR) for AKI and ALI following the administration of remdesivir (exposure) in comparison to a non-exposure period were estimated using the conditional Poisson regression models.

RESULTS

Of 860 COVID-19 patients administered remdesivir during hospitalisation, 334 (38.8%) and 137 (15.9%) had incident ALI and AKI, respectively. Compared with the baseline period, both ALI and AKI risks were increased significantly during the pre-exposure period (ALI: IRR = 6.169, 95% CI = 4.549-8.365; AKI: IRR = 7.074, 95% CI = 3.763-13.298) and remained elevated during remdesivir treatment. Compared to the pre-exposure period, risks of ALI and AKI were not significantly higher in the first 2 days of remdesivir initiation (ALI: IRR = 1.261, 95% CI = 0.915-1.737; AKI: IRR = 1.261, 95% CI = 0.889-1.789) and between days 2 and 5 of remdesivir treatment (ALI: IRR = 1.087, 95% CI = 0.793-1.489; AKI: IRR = 1.152, 95% CI = 0.821-1.616).

CONCLUSION

The increased risks of AKI and ALI associated with intravenous remdesivir treatment for COVID-19 may be due to the underlying SARS-CoV-2 infection. The risks of AKI and ALI were elevated in the pre-exposure period, yet no such increased risks were observed following remdesivir initiation when compared to the pre-exposure period.

[The clinical significance of plasma PTX3 in patients with secondary hemophagocytic lymphohistiocytosis]

Objective: To investigate the significance of plasma pentraxin 3 (PTX3) in patients with secondary hemophagocytic lymphohistiocytosis (sHLH). Methods: Plasma PTX3 levels were tested by ELISA in 48 newly diagnosed sHLH patients, 18 healthy volunteers and 9 lymphoma controls in the First Affiliated Hospital of Nanjing Medical University from January 2017 to July 2019. Clinical parameters were collected, and the correlations with PTX3 levels were analyzed. Results: PTX3 level in newly diagnosed group was significantly higher than that of healthy control group [16.29(1.17-66.00) vs. 0.76(0.01-7.86) μg/L, P<0.01]. Patients with lymphoma-associated HLH(LHLH) had higher plasma level of PTX3 than Fhose with infection-associated HLH (IHLH) [24.29(3.36-66.00) vs. 9.56(1.17-36.50)μg/L, P<0.05]. Plasma PTX3 levels in 48 sHLH patients were positively correlated with serum ferritin (P<0.05). Receiver operating characteristic (ROC) curve for plasma PTX3 levels of sHLH and healthy controls produced a cutoff value at 3.9 μg/L, with its 86.7% sensitivity and 94.4% specificity. And ROC analysis showed that PTX3 17.5 μg/L was the critical value for diagnosis of LHLH from non-LHLH group, that the sensitivity and specificity were 63.0% and 76.2% respectively. The 1-year overall survival (OS) rate in patients with PTX3≥17.5 μg/L was significantly lower in those with PTX3<17.5 μg/L (18.5% vs. 75.8%, P<0.01). Conclusion: These results indicate the potential of PTX3 as a biomarker for diagnosis and prognosis in patients with sHLH.

Association between biochemical control and comorbidities in patients with acromegaly: an Italian longitudinal retrospective chart review study

PURPOSE

Achieving biochemical control (normalization of insulin-like growth factor-1 [IGF-1] and growth hormone [GH]) is a key goal in acromegaly management. However, IGF-1 and GH fluctuate over time. The true potential impact of time-varying biochemical control status on comorbidities is unclear and relies on multiple, longitudinal IGF-1 and GH measurements. This study assessed the association between time-varying biochemical control status and onset of selected comorbidities in patients with acromegaly.

METHODS

Medical charts of adults with confirmed acromegaly and ≥ 6 months of follow-up at an Italian endocrinology center were reviewed. Patients were followed from the first diagnosis of acromegaly at the center until loss to follow-up, chart abstraction, or death. Biochemical control status was assessed annually and defined as IGF-1 ≤ the upper limit of normal, or GH ≤ 2.5 µg/L in the few cases where IGF-1 was unavailable. Time-varying Cox models were used to assess the association between biochemical control status and comorbidities.

RESULTS

Among 150 patients, 47% were female, average age at diagnosis was 43.1, and mean length of follow-up was 10.4 years. Biochemical control was significantly associated with a lower hazard of diabetes (HR = 0.36, 95% CI 0.15; 0.83) and cardiovascular system disorders (HR = 0.54, 95% CI 0.31; 0.93), and a higher hazard of certain types of arthropathy (HR = 1.68, 95% CI 1.04; 2.71); associations for other comorbidities did not reach statistical significance.

CONCLUSION

Results further support the importance of achieving biochemical control, as this may reduce the risk of high-burden conditions, including diabetes and cardiovascular system disorders. The association for arthropathy suggests irreversibility of this impairment. Due to limitations, caution is required when interpreting these results.

[Clinical analysis of secondary hemophagocytic lymphohistiocytosis complicated with capillary leak syndrome]

目的

探讨继发性噬血细胞性淋巴组织细胞增多症（sHLH）合并毛细血管渗漏综合征（CLS）的临床特征。

方法

回顾性分析2015年1月至2017年12月江苏省人民医院收治的87例sHLH患者的临床及实验室资料，其中21例合并CLS（CLS-sHLH组），66例未合并CLS（非CLS-sHLH组）。比较两组的临床表现、实验室检查、治疗及预后差异。

结果

比较CLS-sHLH组和非CLS-sHLH组患者引起sHLH的病因，差异无统计学意义（P>0.05）。CLS-sHLH组患者ANC、血清纤维蛋白原、白蛋白较非CLS-sHLH组降低，而甘油三酯较非CLS-sHLH组升高（P值均<0.05）。CLS-sHLH组患者均有不同程度水肿、体重增加、低血压、低蛋白血症、少尿及多浆膜腔积液。其中15例患者CLS症状消失，CLS中位好转时间为7（5~14）d。6例患者CLS症状未消失，并于15（6~30）d死亡。CLS-sHLH组中位OS时间低于非CLS-sHLH组（75 d对未达到，P=0.031）。

结论

在sHLH患者中，CLS的发生可能与sHLH的原发病无明显相关。严重的ANC、纤维蛋白原及白蛋白减低，甘油三酯升高，可能是sHLH发生CLS的伴随症状。sHLH合并CLS时预后差。

Soy isoflavones supplementation alleviates disease severity in autoimmune-prone MRL-lpr/lpr mice

Soy isoflavones supplements, which are phyto-oestrogens widely used as alternatives to alleviate menopausal syndromes or prevent chronic diseases, may exert oestrogenic and anti-oestrogenic activities. This study aimed to investigate the effects of soy isoflavones supplement on oestrogen-related autoimmune disease, such as systemic lupus erythematosus, using autoimmune-prone female MRL- lpr/lpr mice. Eighty mice of 8 weeks were divided into five groups: 0 (Control), 2 (Isf 2), 10 (Isf 10) and 20 (Isf 20) mg/kg BW/day Phyto SoyaTM isoflavones or 0.375 mg/kg BW/day tamoxifen (TAM) as the positive control, by tube-feeding. Some mice were killed at age 15 weeks for cellular cytokine secretion. The data suggested that the Isf 20 and TAM groups had higher weight gain and survival compared with the control group. At age 22 weeks, the Isf 20 group still had 75% survival comparable to mice treated with TAM. At age 14 weeks, the TAM group showed significantly lower serum anti-double-stranded (ds) DNA IgG and anti-cardiolipin IgG. The mice in the Isf 10 and Isf 20 groups also had lower anti-dsDNA IgG and anti-cardiolipin IgG. The interferon (IFN)-γ secretion from mitogen-stimulated T cells in the Isf 20 and TAM groups were significantly lower than those of control mice. Furthermore, the oestrogenic activity of the methanol extracts of soy isoflavones for oestrogen receptor (ER)β, but not ERα, significantly increased, suggesting that soy isoflavones have a selective modulation of ER activation. Thus, soy isoflavone supplementation did not aggravate murine lupus, but apparently ameliorated the disease.

Particulate debris collected during carotid stenting: are we missing something?

Particulate and histopathologic examination of atherosclerotic material collected during carotid artery stenting is presented, illustrating the limitations of current knowledge regarding the use of distal protection devices (DPD) during this novel vascular intervention.

Minimally invasive approaches to treat simultaneous occurrence of glioblastoma multiforme and intracranial aneurysm -- case report

Primary brain tumors associated with intracranial aneurysm are rare. A combination of glioblastoma multiforme (GBM) with cerebral aneurysm is even more rare. We present a 67-year-old female, who suffered from progressive weakness of the right limbs and dysphasia for 2 days. She was referred from another hospital with impression of having a brain tumor. The non-enhanced computed tomographic (CT) scan of the brain showed a mass lesion over the left parietal region, and another tiny lesion with relatively high density over the left suprasellar region. After admission, the carotid angiogram revealed a 13 x 12 x 14 mm aneurysm with a base about 8 mm from the anterior wall of the left supraclinoid internal carotid artery (ICA) between the left ophthalmic artery and the left anterior choroid artery. We first clipped the aneurysm by a basal pterion keyhole approach. One week later, the tumor was en bloc removed by a small left parietal craniotomy under the guidance of a navigator. The final diagnosis was confirmed by histopathological examination as GBM. After the surgeries, the patient received palliative radiotherapy with a dose of 4000 cGy. She recovered well with no evidence of recurrence of the tumor one year after the operations. In this report, the careful diagnosis and the possible mechanisms of concurring GBM and cerebral aneurysm, as well as the strategies of surgical treatment involving minimally invasive approaches are discussed.

[Evaluation of positron emission tomography in diagnosing and staging of lung cancer]

OBJECTIVE

To evaluate positron emission tomography (PET) in diagnosing and staging of lung cancer.

METHODS

One hundred and forty-seven patients (93 with lung cancer, 15 with lung metastatic tumors, 39 with benign lesions) were involved in the study. 163 whole body examinations (twice in 12 cases and 3 times in 2 cases) were performed after injection of 18F-fluro-deoxy-glucose (18FDG) with a Siemens ECAT EXACT HR + PET system. The results of PET were compared with pathological diagnoses (112 cases), clinical follow-up (35 cases), CT (68 malignant and 30 benign cases), and other imaging diagnoses.

RESULTS

For the 147 cases with lung lesions, the sensitivity, specificity, and accuracy of FDG PET in differentiating the malignant from the benign were 97.2%, 89.7%, and 94.6% respectively. For the 93 lung cancer cases, more lesions were detected by PET in 58 (62.4%) cases, and changed staging in 36 (38.7%). In the 98 cases examinations, PET positive findings were consistent with CT in 39 (39.8%) cases; PET detected more lesions than CT in 29 (29.6%) cases; the lesions detected by CT were negative or with low uptake in the PET images in 30 (30.6%) cases, and they were finally proved as benign by follow-up. However, CT provided better detailed anatomical structures of the lesions than PET, and image fusion should give more information about the lesions.

CONCLUSIONS

FDG PET had advantages in diagnosing and staging of lung cancer by providing metabolic information of the lesions. Comparison and fusion of PET with CT will give much help to clinical diagnosis.

Endoscope-assisted microsurgery for treatment of a suprasellar craniopharyngioma presenting precocious puberty

Being the most common childhood tumor to involve the hypothalamus and pituitary gland, craniopharyngioma, a histologically benign tumor, is usually related to growth retardation and hypogonadism. The presentation of precocious puberty is very rare for a hypothalamic craniopharyngioma. Here, we report such a case. The female patient had presented with symptoms of menarche and breast development since she was 6 years old. Hormonal therapy with a gonadotropin-releasing hormone analogue was instituted to cease precocious puberty but was unsuccessful. Magnetic resonance imaging of the sella showed a 1-cm tumor in the hypothalamic area. Through a pterional approach, the tumor was removed en bloc with endoscope-assisted microsurgery. After the operation, our patient's symptoms improved, so the hormone therapy was discontinued. This extremely unique association of craniopharyngioma and precocious puberty, the causes and mechanisms involved along with the advantages of endoscope-assisted microsurgery are discussed.

The abnormality of glucose transporter in the erythrocyte membrane of Chinese type 2 diabetic patients

Type 2 diabetes mellitus is characterized by impaired glucose uptake. With a photometric method of recording the erythrocyte suspension absorption during the course of glucose transport across the membranes, we observed that the initial rate of glucose zero-trans entry was decreased significantly in 30 Chinese type 2 diabetic patients as compared to 25 healthy controls. The rate of glucose infinite-cis efflux exhibited no difference between the patients and controls. The measurement of temperature dependence of glucose transport showed that the activation energy for glucose entry was increased in diabetic patients. The inhibitory constant of glucose entry by cytochalasin B (CB) in patients was similar to that of the controls. However, we found that the inhibitory constant was increased significantly in the patient erythrocytes after phloretin treatment. After the erythrocytes were made into stripped white ghosts, the fluorescence quenching experiment was performed. Glucose, CB and phloretin can quench the fluorescence of tryptophan residues in the glucose transporter 1, GLUT1. The abnormality of fluorescence quenching in the erythrocyte membranes of patients was observed. The transfer tendency of tryptophan residues from the hydrophilic environment to the hydrophobic environment was decreased in patient ghosts as binding with glucose, and the opposite tendency appeared as CB and phloretin instead of glucose. We conclude that the decreased in glucose entry in the erythrocyte membranes of diabetic patients was due to the GLUT1 change in structure - mostly the outer domain of the glucose transporter.

Quantitative sensory testing and risk factors of diabetic sensory neuropathy

The goal of this study was to identify risk factors for diabetic peripheral sensory neuropathy in type 2 diabetes mellitus in a Chinese population. Peripheral sensory neuropathy was detected by quantitative sensory testing (5.07/10 g monofilament, neurometer and 128-Hz Riedel Seiffert graduated tuning fork). Those who had two or more abnormal quantitative sensory testings were defined as having diabetic sensory neuropathy. Of the 558 non-insulin dependent diabetes mellitits subjects, 62 (11.1%) had peripheral neuropathy. In 59 (10.6%) detection was by monofilament testing, 45 (8.1%) by graduated tuning fork, and 189 (33.9%) by neurometer. In a multivariate logistic regression model, age and insulin therapy were significantly associated with peripheral neuropathy. Age, serum triglyceride, height, and fasting plasma glucose were independently associated with large fiber neuropathy. Our results confirm the previously identified multiple risk factors of diabetic neuropathy. Different quantitative sensory testings detect different nerve fiber defects. The weak correlation between these tests indicates the need to use more than one test in screening for diabetic neuropathy.

Adrenal cancer with hypertension but low plasma renin and aldosterone

Patients with malignant lesions of the adrenal gland may present with a syndrome of excess mineralocorticoids. Both primary hyperaldosteronism and excess mineralocorticoids other than aldosterone resulting from adrenal carcinoma have rarely been reported. In most patients with adrenal tumors secreting mineralocorticoids other than aldosterone, distant metastasis had already occurred at the time of diagnosis and the prognosis was poor. We present a rare case of adrenal cancer with hypertension in a patient with low plasma renin activity and a low plasma aldosterone concentration. The patient's blood pressure returned to normal after removal of the tumor. The patient is still alive and without recurrence 6 years after surgery. This case illustrates the value of thorough evaluation of hypertension and prompt surgical treatment for patients with adrenal cancer.

The physiological state as a modifier of radiation-induced cytotoxicity in heterogeneous murine tumor cells growing in vitro

The oxic radiation response (cytotoxicity) of two heterogeneous murine tumor-cell lines cultured in vitro was studied as a function of the cell's physiological state at the time of X-irradiation. The proliferating (P) 66 and 67 cells displayed equal radiosensitivities; however, the quiescent (Q) cells were considerably more radiosensitive than the P cells, and the 66Q cells were even more radiosensitive than the 67Q cells. Also, the 66Q cells continued to proliferate slowly with about 85 per cent in the G1 phase and 10 per cent in the S phase, while the 67 Q cells displayed a more complete G1 arrest (92-95 per cent). A detailed analysis of the metabolic status vs cell-cycle age (i.e. G1 vs S phase) indicated that the cell-cycle age was the predominant factor influencing radiation-induced cytotoxicity in 67 cells. The data also showed that in the plateau phase Q-cell cultures, pH and cell contact were not influencing factors and that the increased radiosensitivity of the Q cells could not be explained on the basis of energy deprivation. Moreover, the 66Q, but not the 67Q cells displayed an increased sensitivity in addition to that caused by the predominant cell-cycle age shift. This extra increase in radiosensitivity is of unknown metabolic origin, but could be related to cellular membrane fragility in the stressed 66Q cells since this extra component of Q-cell radiosensitivity was reduced both by refeeding (metabolic activation) 4 h before X-irradiation and by delayed plating while incubating the cells in Q medium at 37 degrees C after X-irradiation.