Liver injury in COVID-19: Diagnosis and associated factors

COVID-19 and the liver: A brief and core review

Coronavirus disease 2019 has a wide range of clinical spectrum from asymptomatic infection to severe infection resulting in death within a short time. Currently, it is known that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) does not only cause a respiratory tract infection but a more complicated disease that can lead to multiple system involvement including the liver. Herein, we evaluate the epidemiology, the impact of liver injury/ dysfunction on disease prognosis, the pathophysiological mechanisms and management of liver injury. More than one-fourth of the patients have abnormal liver function tests, mostly a mild-to-moderate liver dysfunction. Liver injury is significantly associated with a poor clinical outcome. Direct cytotoxic effect of SARS-CoV-2, the immune response ("cytokine storm"), the complications related to the disease, and drugs used in the treatments are the pathophysiological mechanisms responsible for liver injury. However, the exact mechanism is not yet clearly explained. The binding of SARS-CoV-2 to the angiotensin-converting enzyme 2 receptors and entering the hepatocyte and cholangiocytes can cause cytotoxic effects on the liver. Excessive immune response has an important role in disease progression and causes acute respiratory distress syndrome and multi-organ failures accompanied by liver injury. Treatment drugs, particularly lopinavir/ritonavir, remdesivir and antibiotics are a frequent reason for liver injury. The possible reasons should be meticulously investigated and resolved.

Abnormal Indexes of Liver and Kidney Injury Markers Predict Severity in COVID-19 Patients

BACKGROUND

SARS-CoV-2 can damage not only the lungs but also the liver and kidney. Most critically ill patients with coronavirus disease 2019 (COVID-19) have liver and kidney dysfunction. We aim to investigate the levels of liver and kidney function indexes in mild and severe COVID-19 patients and their capability to predict the severity of the disease.

METHODS

The characteristics and laboratory indexes were compared between patients with different conditions. We applied binary logistic regression to find the independent risk factors of severe patients. Receiver operating characteristic (ROC) analysis was used to predict the severity of COVID-19 using the liver and kidney function indexes.

RESULTS

This study enrolled 266 COVID-19 patients, including 235 mild patients and 31 severe patients. Compared with mild patients, severe patients had lower albumin (ALB) and higher alanine aminotransferase (ALT), aspartate aminotransferase (AST), and urea nitrogen (BUN) (all p<0.001). Binary logistic regression analysis also identified ALB [OR=0.273 (0.079-0.947), p=0.041] and ALT [OR=2.680 (1.036-6.934), p=0.042] as independent factors of severe COVID-19 patients. Combining ALB, ALT, BUN, and LDH exhibited the area under ROC at 0.914, with a sensitivity of 86.7% and specificity of 83.0%.

CONCLUSION

COVID-19 patients, especially severe patients, have damage to liver and kidney function. ALT, AST, LDH, and BUN could be independent factors for predicting the severity of COVID-19. Combining the ALB, ALT, BUN, and LDH could predict the transition from mild to severe in COVID-19 patients.

Laboratory hematologic features of COVID-19 associated liver injury: A systematic review

BACKGROUND

Liver injury is a common complication of infection by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. The utility of laboratory hematology data in the diagnosis and risk stratification of patients with coronavirus disease 2019 (COVID-19) has not been comprehensively examined.

AIM

To address the following. (1) Are the abnormalities in hematologic parameters seen in the general population of patients with COVID-19 also seen in those patients with associated liver injury? (2) Is liver injury in COVID-19 a sign of severe disease and does liver injury correlate with hematologic markers of severe disease? And (3) What is the quality of this evidence?

METHODS

To address these questions, a comprehensive systematic review was performed. We searched the peer reviewed medical literature using MEDLINE (PubMed interface), Web of Science, and EMBASE for cohort studies that specifically addressed liver injury and COVID-19 without limitation of date of publication or language. A quality assessment of the studies was performed using the Newcastle-Ottawa Scale.

RESULTS

Thirty-two articles were suitable for inclusion in our systematic review. These included 22 articles with a cohort of COVID-19 patients with liver injury, 5 comparing non-severe vs severe COVID-19 populations in which liver injury was addressed, and 5 other cohort studies with a focus on liver injury. White blood cell count, absolute neutrophil count, absolute lymphocyte count (ALC), and hemoglobin were the parameters most helpful in distinguishing COVID-19 with liver injury from COVID-19 without liver injury. ALC and d-dimer were identified as being potentially useful in distinguishing non-severe from severe COVID-19. Liver injury was more frequently seen in cohorts with severe disease. Most studies were of high quality (24/48, 86%) with 4/28 (14%) of moderate quality and 0 of low quality.

CONCLUSION

Our study supports the use of select hematologic parameters in diagnosis and risk stratification of liver injury in COVID-19 patients. Although of overall high quality, the current medical literature is limited by the small number of studies with high statistical power and the variable definition of COVID-19 liver injury in the literature.

Stay (GI) Healthy: COVID-19 and Gastrointestinal Manifestations

SARS-CoV-2 is the virus responsible for COVID-19, whose clinical spectrum ranges widely, both in terms of severity and multi-organicity. SARS-CoV-2 mainly involves the respiratory tract, causing from a flu-like syndrome to interstitial pneumonia and acute respiratory distress syndrome. Although its entry receptor, angiotensin-converting-enzyme 2, is typically expressed in epithelial cells of the airways, extra-pulmonary involvement has been consistently demonstrated since the beginning of the outbreak. Gastrointestinal manifestations in COVID-19 may be explained by the abundant expression of ACE2 in the digestive tract. Moreover, not only COVID-19 patients often present with GI symptoms (diarrhea, nausea/vomiting, abdominal pain) and liver tests abnormalities, but there are also data showing active viral replication in the GI tract and possible fecal-oral transmission. Aim of this review is to summarize the evidence regarding prevalence and clinical significance of GI involvement and liver abnormalities in patients with COVID-19, providing the reader with evidence-based recommendations on the management of these conditions.