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Yadlapati S, Jarrett SA, Baik D, Chaaya A. COVID-19 related biliary injury: A review of recent literature. World J Gastroenterol 2023; 29:2127-2133. [PMID: 37122603 PMCID: PMC10130971 DOI: 10.3748/wjg.v29.i14.2127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 03/11/2023] [Accepted: 03/21/2023] [Indexed: 04/13/2023] Open
Abstract
Since its emergence in 2019, it has become apparent that coronavirus 2019 (COVID-19) infection can result in multi systemic involvement. In addition to pulmonary symptoms, hepatobiliary involvement has been widely reported. Extent of hepatic involvement ranges from minor elevation in liver function tests (LFTs) to significant hepatocellular or cholestatic injury. In majority of cases, resolution of hepatic injury or improvement in LFTs is noted as patients recover from COVID-19 infection. However, severe biliary tract injury progressing to liver failure has been reported in patients requiring prolonged intensive care unit stay or mechanical ventilation. Due to the timing of its presentation, this form of progressive cholestatic injury has been referred to as COVID-19 cholangiopathy or post-COVID-19 cholangiopathy, and can result in devastating consequences for patients. COVID-19 cholangiopathy is recognized by dramatic elevation in serum alkaline phosphatase and bilirubin and radiologic evidence of bile duct injury. Cholangiopathy in COVID-19 occurs weeks to months after the initial infection and during the recovery phase. Imaging findings and pathology often resemble bile duct injury associated with primary or secondary sclerosing cholangitis. Etiology of COVID-19 cholangiopathy is unclear. Several mechanisms have been proposed, including direct cholangiocyte injury, vascular compromise, and cytokine release syndromes. This review summarizes existing data on COVID-19 cholangiopathy, including reported cases in the literature, proposed pathophysiology, diagnostic testing, and long-term implications.
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Affiliation(s)
- Sujani Yadlapati
- Department of Gastroenterology, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ 08103, United States
| | - Simone A. Jarrett
- Department of Internal Medicine, Einstein Medical Center, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19140, United States
| | - Daniel Baik
- Department of Gastroenterology, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ 08103, United States
| | - Adib Chaaya
- Department of Gastroenterology, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ 08103, United States
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Wongtanasarasin W. Cholestatic liver injury: A rare but fatal complication during and after COVID-19 infection. World J Virol 2022; 11:435-442. [PMID: 36483106 PMCID: PMC9724201 DOI: 10.5501/wjv.v11.i6.435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 09/21/2022] [Accepted: 10/19/2022] [Indexed: 11/23/2022] Open
Abstract
The 2019 coronavirus disease (COVID-19), resulting from the severe acute respiratory syndrome 2 virus, has transformed our globe and provided a new perspective on respiratory tract infections. However, COVID-19 would not be recognized as a condition restricted to only pneumonia. This narrative review was conducted by searching manuscripts in several databases, including PubMed/ MEDLINE, Web of Science, and Reference Citation Analysis, from December 2019 to July 2022. Many studies have revealed a broad spectrum of potential systemic symptoms, including biliary complications. Although biliary injury has been observed in a very low proportion of COVID-19 patients, it is associated with increased mortalities and long-term morbidities. We identify a cholangiopathy condition in individuals during infection and after recovering from severe COVID-19, defined by a significant increase in serum alkaline phosphatase and signs of bile duct injury. Understanding the pathogeneses behind this condition would help us develop new techniques to prevent these complications. This review thoroughly discusses and summarizes the current information regarding COVID-19-associated cholangiopathy. In addition, the possible explanations for COVID-19-associated cholangiopathy are presented. Since the exact pathogenesis may not be concluded, this review could provide relevant information to encourage additional investigations shortly.
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Affiliation(s)
- Wachira Wongtanasarasin
- Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, CA 95817, United States
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Huang S, Liu L, Mei HF, Zhang QW, Zhang X, Xu XT, Wang XZ, Huang X, Wang T, Jiang ZZ, Zhang LY, Sun LX. Altered integrity of hepatocyte tight junctions in rats with triptolide-induced cholestasis. Chin J Nat Med 2021; 19:188-94. [PMID: 33781452 DOI: 10.1016/S1875-5364(21)60020-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Indexed: 12/13/2022]
Abstract
Triptolide (TP), an active component of Tripterygium wilfordiiHook. f. (TWHF), has been widely used for centuries as a traditional Chinese medicine. However, the clinical application of TP has been restricted due to multitarget toxicity, such as hepatotoxicity. In this study, 28 days of oral TP administration (100, 200, or 400 μg·kg-1·d-1) induced the occurrence of cholestasis in female Wistar rats, as evidenced by increased serum levels of γ-glutamyl transpeptidase (γ-GGT), alkaline phosphatase (ALP) and hepatic total bile acids (TBAs). In addition, the heptocyte polarity associated with the strcture of tight junctions (TJs) was disrupted in both rats and sandwich-cultured primary hepatocytes. Immunoblotting revealed decreased expression of the TJ-associated proteins occludin, claudin-1, and zonula occludens protein (ZO-1), and downregulated mRNA levels of these TJs was also detected by real-time PCR. An immunofluorescence analysis showed abnormal subcellular localization of occludin, claudin-1 and ZO-1, which was also confirmed by transmission electron microscopy. Moreover, the concentration of FITC-dextran, a marker of paracellular penetration, was found to increase rapidly in bile increased rapidly (within 6 minutes) after treatment with TP, which indicated the functional impairment of TJs. Taken together, these results suggest that the administration of TP for 28 consecutive days to rats could induce cholestatic injury in the liver, and the increased paracellular permeability might play an important role in these pathological changes.
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Villar-Lorenzo A, Rada P, Rey E, Marañón P, Arroba AI, Santamaría B, Sáiz J, Rupérez FJ, Barbas C, García-Monzón C, Valverde ÁM, González-Rodríguez Á. Insulin receptor substrate 2 (IRS2) deficiency delays liver fibrosis associated with cholestatic injury. Dis Model Mech 2019; 12:dmm.038810. [PMID: 31262748 PMCID: PMC6679376 DOI: 10.1242/dmm.038810] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 06/21/2019] [Indexed: 12/12/2022] Open
Abstract
Insulin receptor substrate 2 (IRS2) is a key downstream mediator of insulin and insulin-like growth factor 1 (IGF1) signalling pathways and plays a major role in liver metabolism. The aim of this study was to investigate whether IRS2 had an impact on the hepatic fibrotic process associated with cholestatic injury. Bile duct ligation (BDL) was performed in wild-type (WT) and Irs2-deficient (IRS2KO) female mice. Histological and biochemical analyses, together with fibrogenic and inflammatory responses were evaluated in livers from mice at 3, 7 and 28 days following BDL. We also explored whether activation of human hepatic stellate cells (HSCs) induced by IGF1 was modulated by IRS2. IRS2KO mice displayed reduced disruption of liver histology, such hepatocyte damage and excess deposition of extracellular matrix components, compared with WT mice at 3 and 7 days post-BDL. However, no histological differences between genotypes were found at 28 days post-BDL. The less pro-inflammatory profile of bile acids accumulated in the gallbladder of IRS2KO mice after BDL corresponded with the reduced expression of pro-inflammatory markers in these mice. Stable silencing of IRS2 or inhibition of ERK1/2 reduced the activation of human LX2 cells and also reduced induction of MMP9 upon IGF1 stimulation. Furthermore, hepatic MMP9 expression was strongly induced after BDL in WT mice, but only a slight increase was found in mice lacking IRS2. Our results have unravelled the signalling pathway mediated by IGF1R–IRS2–ERK1/2–MMP9 as a key axis in regulating HSC activation, which might be therapeutically relevant for targeting liver fibrosis. Summary: IRS2 is a key mediator of IGF1R signalling in hepatic stellate cell activation in cholestatic liver injury.
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Affiliation(s)
- Andrea Villar-Lorenzo
- Instituto de Investigaciones Biomédicas Alberto Sols (CSIC-UAM), 28029 Madrid, Spain.,Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos IIII, 28029 Madrid, Spain
| | - Patricia Rada
- Instituto de Investigaciones Biomédicas Alberto Sols (CSIC-UAM), 28029 Madrid, Spain.,Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos IIII, 28029 Madrid, Spain
| | - Esther Rey
- Unidad de Investigación Hepática, Hospital Universitario Santa Cristina, Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa, 28009 Madrid, Spain
| | - Patricia Marañón
- Unidad de Investigación Hepática, Hospital Universitario Santa Cristina, Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa, 28009 Madrid, Spain
| | - Ana I Arroba
- Instituto de Investigaciones Biomédicas Alberto Sols (CSIC-UAM), 28029 Madrid, Spain
| | - Beatriz Santamaría
- Instituto de Investigaciones Biomédicas Alberto Sols (CSIC-UAM), 28029 Madrid, Spain
| | - Jorge Sáiz
- Centre for Metabolomics and Bioanalysis (CEMBIO), Faculty of Pharmacy, Universidad San Pablo CEU, Campus Monteprincipe, Boadilla del Monte, 28668, Madrid, Spain
| | - Francisco J Rupérez
- Centre for Metabolomics and Bioanalysis (CEMBIO), Faculty of Pharmacy, Universidad San Pablo CEU, Campus Monteprincipe, Boadilla del Monte, 28668, Madrid, Spain
| | - Coral Barbas
- Centre for Metabolomics and Bioanalysis (CEMBIO), Faculty of Pharmacy, Universidad San Pablo CEU, Campus Monteprincipe, Boadilla del Monte, 28668, Madrid, Spain
| | - Carmelo García-Monzón
- Unidad de Investigación Hepática, Hospital Universitario Santa Cristina, Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa, 28009 Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos IIII, 28029 Madrid, Spain
| | - Ángela M Valverde
- Instituto de Investigaciones Biomédicas Alberto Sols (CSIC-UAM), 28029 Madrid, Spain .,Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos IIII, 28029 Madrid, Spain
| | - Águeda González-Rodríguez
- Unidad de Investigación Hepática, Hospital Universitario Santa Cristina, Instituto de Investigación Sanitaria del Hospital Universitario de La Princesa, 28009 Madrid, Spain .,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos IIII, 28029 Madrid, Spain
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Abstract
Interest in drug-induced liver injury (DILI) has dramatically increased over the past decade, and it has become a hot topic for clinicians, academics, pharmaceutical companies and regulatory bodies. By investigating the current state of the art, the latest scientific findings, controversies, and guidelines, this review will attempt to answer the question: Do we know everything? Since the first descriptions of hepatotoxicity over 70 years ago, more than 1000 drugs have been identified to date, however, much of our knowledge of diagnostic and pathophysiologic principles remains unchanged. Clinically ranging from asymptomatic transaminitis and acute or chronic hepatitis, to acute liver failure, DILI remains a leading causes of emergent liver transplant. The consumption of unregulated herbal and dietary supplements has introduced new challenges in epidemiological assessment and clinician management. As such, numerous registries have been created, including the United States Drug-Induced Liver Injury Network, to further our understanding of all aspects of DILI. The launch of LiverTox and other online hepatotoxicity resources has increased our awareness of DILI. In 2013, the first guidelines for the diagnosis and management of DILI, were offered by the Practice Parameters Committee of the American College of Gastroenterology, and along with the identification of risk factors and predictors of injury, novel mechanisms of injury, refined causality assessment tools, and targeted treatment options have come to define the current state of the art, however, gaps in our knowledge still undoubtedly remain.
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Affiliation(s)
- Tamara Alempijevic
- Tamara Alempijevic, Simon Zec, Tomica Milosavljevic, University of Belgrade, School of Medicine, 11000 Belgrade, Serbia
| | - Simon Zec
- Tamara Alempijevic, Simon Zec, Tomica Milosavljevic, University of Belgrade, School of Medicine, 11000 Belgrade, Serbia
| | - Tomica Milosavljevic
- Tamara Alempijevic, Simon Zec, Tomica Milosavljevic, University of Belgrade, School of Medicine, 11000 Belgrade, Serbia
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Gudnason HO, Björnsson HK, Gardarsdottir M, Thorisson HM, Olafsson S, Bergmann OM, Björnsson ES. Secondary sclerosing cholangitis in patients with drug-induced liver injury. Dig Liver Dis 2015; 47:502-7. [PMID: 25840876 DOI: 10.1016/j.dld.2015.03.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Revised: 02/06/2015] [Accepted: 03/04/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Secondary sclerosing cholangitis has clinical features similar to primary sclerosing cholangitis but originates from a known pathological entity. Secondary sclerosing cholangitis has not been investigated in patients with drug-induced liver injury. METHODS Overall 102 patients diagnosed with drug-induced liver injury were identified and magnetic resonance cholangiopancreatography images of 25 patients were reviewed. RESULTS Ten patients (all females) out of 102 had confirmed features of secondary sclerosing cholangitis on biliary imaging. Overall 70% of patients with sclerosing cholangitis had jaundice vs. 25% without sclerosing cholangitis (p<0.01). All sclerosing cholangitis patients had cholestatic/mixed type of liver injury and compared with patients with cholestatic/mixed liver injury without confirmed abnormal MRCP (n=52), they also had more frequently jaundice, 70% vs. 23% (p=0.0065), higher peak alkaline phosphatase 551 (352-716) vs. 329 (202-543) (p=0.055) and longer time to resolution of liver injury 152 days (123-353) vs. 62 days (36-91) than patients without confirmed sclerosing cholangitis (p<0.0009). CONCLUSIONS Our results indicate that drugs can lead to bile duct injury visualized on imaging. This should be a part of the differential diagnoses of secondary sclerosing cholangitis. These patients were more likely to present with jaundice and longer recovery of liver injury than other patients with cholestatic/mixed type of drug-induced liver injury.
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Hunt CM, Yuen NA, Stirnadel-Farrant HA, Suzuki A. Age-related differences in reporting of drug-associated liver injury: data-mining of WHO Safety Report Database. Regul Toxicol Pharmacol 2014; 70:519-26. [PMID: 25236535 DOI: 10.1016/j.yrtph.2014.09.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 08/18/2014] [Accepted: 09/09/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND/AIMS Age-differences in the frequency and manifestations of drug-induced liver injury are not fully characterized. Data-mining analyses were performed to assess the impact of age on liver event reporting frequency with different phenotypes and agents. METHODS 236 drugs associated with hepatotoxicity were evaluated using the Empirical Bayes Geometric Mean (EBGM) of the relative reporting ratio with 90% confidence interval (EB05 and EB95) calculated for the age groups: 0-17, 18-64, and⩾65years (or elderly), for overall, serious (acute liver failure), hepatocellular, and cholestatic liver injury, using the WHO Safety Report Database. RESULTS Overall, cases of age 0-17, 18-64, and 65years or older comprised 6%, 62%, and 32% of liver event reports. Acute liver failure and hepatocellular injury were more frequently reported among children compared to adults and the elderly while reports with cholestatic injury were more frequent among the elderly (p<0.00001). A potential to cause mitochondrial dysfunction was more prevalent among the drugs with increased pediatric reporting frequency while high lipophilicity and biliary excretion were more common among the drugs associated with higher reporting frequency in the elderly. CONCLUSION Age-specific phenotypes and potential drug properties associated with age-specific hepatotoxicity were identified in reported liver events; further analyses are warranted.
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Affiliation(s)
- Christine M Hunt
- Division of Gastroenterology, Duke University Medical Center, Durham, NC, United States; Durham Veterans Administration Medical Center, Durham, NC, United States.
| | - Nancy A Yuen
- Global Clinical Safety and Pharmacovigilance, GlaxoSmithKline, Research Triangle Park, NC, United States
| | | | - Ayako Suzuki
- Division of Gastroenterology, University of Arkansas for Medical Sciences, Little Rock, AR, United States; Division of Gastroenterology, Central Arkansas Veterans Healthcare System, Little Rock, AR, United States
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