COVID-19 and the liver: Are footprints still there?

The coronavirus disease 2019 (COVID-19) hit the entire world as a global pandemic and soon became the most important concern for all patients with chronic diseases. An early trend in higher mortality in patients with acute respiratory distress attracted all researchers to closely monitor patients for the involvement of other systems. It soon became apparent that patients with chronic liver diseases are at increased risk of mortality given their cirrhosis-associated immune dysfunction. Additionally, liver function abnormalities were noted in patients with severe COVID-19. Profound cytokine storm, direct viral infection, drugs and reactivation of viral infections were causes of deranged liver functions. Here, we discuss the relation between COVID-19 and chronic liver disease, specifically cirrhosis, hepatitis B, hepatitis C, and non-alcoholic fatty liver disease (NAFLD), as well as the liver manifestations of COVID-19. The metabolic syndrome, obesity, diabetes mellitus and NAFLD were found to worsen outcome in different studies reported worldwide. Decompensated cirrhosis should be considered a risk factor for death and severe COVID-19. Recently, COVID-19 related cholangiopathy has also been reported with changes of secondary sclerosing cholangitis. The long-term persistence of viral antigens in gut epithelia raises concern regarding the future risk of autoimmune liver diseases.

Acute Hepatitis in an Immunosuppressed Patient: A Dilemma

Acute hepatitis in patients on chemotherapy has always been challenging. Demystifying the truth becomes essential to continue chemotherapy. Wepresent a case of carcinoma buccal mucosa who developed acute hepatitis following a single dose of cisplatin and radiotherapy. In the background of a history of chronic alcoholism, and alcohol abstinence of more than 3 months, acute alcoholic hepatitis was unlikely. Though he had occult hepatitis B with HBsAg negative and positive IgG anti-HBc antibody status, however, with undetectable HBV DNA PCR quantitative, hepatitis B was unlikely to be the cause of acute hepatitis. With all viral markers including atypical viruses and autoimmune work-up being negative, it was a real-time challenge to find the exact cause.

How to cite this article

Gupta T. Acute Hepatitis in an Immunosuppressed Patient: A Dilemma. Euroasian J Hepato-Gastroenterol 2023;13(1):26-27.

Nonalcoholic steatohepatitis and hepatocellular carcinoma: Beyond the boundaries of the liver

The burden of non-alcoholic steatohepatitis (NASH) related hepatocellular carcinoma (HCC) is drawing attention due to the emerging epidemic of obesity and metabolic syndrome and is expected to increase in the near future. Antidiabetic medications, air pollutants, and newer genetic mutations are latest concerns as risk factors for HCC development in patients with NASH. Although molecular signatures are very accurate, they are not cost-effective and cannot be applied in larger population due to logistic issues. We need multicentric longitudinal studies including diverse geographical areas to evaluate the complex interplay of different risk factors and genetics in these patients.

Hepatitis B core-related antigen: Are we near a treatment endpoint?

Different serological and virological markers in chronic hepatitis B patients guide staging of viral infection, and initiation and response to therapy. Due to the persistence of intrahepatic covalently closed circular DNA (cccDNA) in the hepatocyte nucleus, hepatitis B is not curable. Even after undetectable hepatitis B virus DNA levels, the persistence of hepatitis B surface antigen and novel markers such as hepatitis B core-related antigen (HBcrAg) indicate the persistence of intrahepatic cccDNA. In this study, HBcrAg levels at baseline and after 24 and 48 wk of antiviral therapy predicted hepatitis B e antigen seroconversion. Due to the poor sensitivity of assays and detectable levels in HBsAg-negative patients, the long-term utility of HBcrAg needs future research.

Predictors of mortality at 28-days in infection associated acute kidney injury in cirrhosis

BACKGROUND

Acute kidney injury (AKI) in cirrhosis is important complication with poor outcomes. And infections are common cause for acute decompensation. Infections in cirrhosis lead to acute deterioration of hemodynamics leading to precipitation of AKI.

AIM

To study predictors of mortality in patients with infection-associated AKI in cirrhosis.

METHODS

This was a prospective, observational study conducted at tertiary care centre from January 2018 till April 2019. Total 119 participants with cirrhosis of liver presenting with AKI were included into the study. AKI was defined as per international club of Ascites-AKI criteria 2015. Patients were grouped into infection AKI and non-infection AKI. Non-infection AKI included patients with diuretic induced AKI and pre-renal AKI. Logistic regression analysis was used to determine predictors of mortality at 28-d.

RESULTS

Out of 119 patients, alcohol (n = 104) was most common etiology of cirrhosis. The infection AKI included 67 (56%) patients and non-infection AKI (n = 52) included pre-renal AKI in 36 (30%) and diuretic-induced AKI in 16 (14%) patients. Infection AKI had significantly higher bilirubin, higher international normalized ratio (INR), low serum sodium, higher total leukocyte count (TLC) and higher prevalence of hepatic encephalopathy (HE) as compared to non-infection AKI. Infection AKI had higher progression of AKI (19/67 vs 2/52; P = 0.01) and 28-d mortality (38/67 vs 4/5; P ≤ 0.01) as compared to non-infection AKI. At 28-d, non-survivors (n = 42) had significantly higher bilirubin, higher INR, low serum sodium, higher TLC and higher prevalence of HE as compared to survivors (n = 77). On subgroup analysis of Infection AKI group, on multivariate analysis, serum bilirubin as well as presence of HE were independent predictors of 28-d mortality. There was no significant difference of mortality at 90-d between two groups.

CONCLUSION

Infection AKI in cirrhosis has a dismal prognosis with higher 28-d mortality as compared to non-infection AKI. Serum bilirubin and presence of HE predict 28-d mortality in infection AKI.

COVID-19 and liver disease: Are we missing something?

Since the coronavirus disease 2019 (COVID-19) has hit the world as a pandemic, researchers all over the world have worked on its diagnostics, prognosticating factors, etc. The present study showed liver enzymes, especially aspartate aminotransferase (AST) levels, to be high in non-survivors with raised AST/alanine aminotransferase ratio. Considering the non-specific nature of AST with its presence in organs other than liver such as muscle, heart, kidney and brain makes it difficult to interpret. Even pre-existing metabolic syndrome and non-alcoholic fatty liver disease are confounding factors for deranged liver functions detected during COVID-19 disease. Therefore, the results of the study should be taken with caution.

Valproate-induced Drug Rash Eosinophilia with Systemic Symptoms Syndrome: An Unknown Hepatotoxicity

Drug rash eosinophilia with systemic symptoms (DRESS syndrome) presents as an acute febrile illness with leukocytosis, eosinophilia, lymphadenopathy, skin rash with acute hepatitis, renal failure, myositis, or systemic organ involvement. Aromatic anticonvulsants like phenytoin, carbamazepine, and phenobarbital cause drug-induced hypersensitivity or DRESS syndrome. However, sodium valproate being nonaromatic compound although known hepatotoxic drug in preexisting chronic liver disease has never been reported to cause DRESS syndrome alone. Here we report an interesting case of DRESS syndrome caused by valproate, which presented as an acute hepatitis illness with rash, renal dysfunction, and typical hematological features of DRESS syndrome within 2 months of the introduction of the drug in an epileptic patient. Patient initially showed a good response to intravenous steroids with improvement in the liver and renal dysfunction. However, later on, developed pancytopenia either due to steroid-induced sepsis or DRESS syndrome-related secondary hemophagocytosis (HPS) due to involvement of bone marrow as a rare occurrence and succumbed to illness.

How to cite this article

Gupta T. Valproate-induced Drug Rash Eosinophilia with Systemic Symptoms Syndrome: An Unknown Hepatotoxicity. Euroasian J Hepato-Gastroenterol 2019;9(2):102-103.

Prediction of Cirrhosis in Patients with Chronic Hepatitis C by Genotype 3

Background

Genotype 3 increases fibrosis in chronic hepatitis C (CHC).

Aim

To evaluate the effect of the hepatitis C virus (HCV) genotype on prevalence and severity of liver disease in CHC.

Materials and methods

Nine hundred and forty-nine individuals with positive anti-HCV from June 2016 to May 2017 were enrolled in the study. We compared biochemical and hematological parameters, HCV RNA load, transient elastography, and ultrasound, in genotype 3 and nongenotype 3 patients. Cirrhosis was diagnosed in patients with liver stiffness measurement (LSM) ≥13 kPa.

Results

Out of 835 CHC patients, overall, genotype 3 had higher LSM (11.3 vs 7.62, p = 0.01), higher aspartate aminotransferase (AST) (88.4 vs 68.6, p = 0.02), and low platelets (228.4 vs 261, p = 0.03) with higher prevalence of cirrhosis (115/415 vs 25/245, p = 0.01) than nongenotype 3. However, decompensation rates were not significantly different between two groups (32/115 vs 7/25, p = 0.98). The subgroup analysis revealed that cirrhotic genotype 3 had advanced age (50 vs 35, p < 0.01), male predominance, and higher AST (74.4 vs 57, p = 0.01) as compared to noncirrhotic genotype 3 patients. On multivariate analysis, age and AST values were higher in cirrhotic than noncirrhotic genotype 3 patients.

Conclusion

Genotype 3 patients have higher prevalence of cirrhosis and fibrosis compared to nongenotype 3 patients; however, decompensation was not different between two groups.

How to cite this article

Gupta T, Aggarwal HK, Goyal S, et al. Prediction of Cirrhosis in Patients with Chronic Hepatitis C by Genotype 3. Euroasian J Hepato-Gastroenterol 2020;10(1):7–10.