Changes in liver biochemistry and tacrolimus levels following the introduction of elexacaftor/tezacaftor/ivacaftor in patients with cystic fibrosis and liver transplant

INTRODUCTION

Elevated liver function tests (LFTs) are reported in individuals with cystic fibrosis (CF) starting elexacaftor/tezacaftor/ivacaftor (ETI). We report our experience with ETI in CF liver transplant patients.

METHOD

All CF liver transplant patients under the care of the Leeds CF team were commenced on ETI. Liver biopsies were performed when ALT >3 times upper limit of normal with or without bilirubin elevation. Treatment was guided by transplant hepatology and CF teams. Clinical data including lung function, LFTs and tacrolimus levels were collected.

RESULTS

Four patients (3 male, 1 female) on tacrolimus were commenced on ETI. Median time post liver transplantation was 6.5 years. Three patients underwent liver biopsy. One biopsy was abnormal with immune-mediated liver injury, which responded to increased immunosuppression. Management of tacrolimus levels proved straightforward.

CONCLUSION

ETI therapy in CF post liver transplant recipients was encouraging. Normal liver biopsy provides re-assurance to continue treatment despite elevated LFTs.

The Enhancement of Hepatic Parenchyma and Portal Vein in different CLD Groups: A Comparative Study of Gadoxetic Acid and Gadopentetate Dimeglumine

BACKGROUND

Chronic liver disease (CLD) will affect the enhancement of hepatic parenchyma and portal vein on abdominal-enhanced MRI.

OBJECTIVE

To investigate the difference in liver parenchyma and portal vein enhancement in patients with CLD of different liver function grades between Gd- EOB-DTPA and Gd-DPTA in the portal venous phase (PVP).

METHODS

This retrospective study included 218 patients with CLD who had undergone abdominal enhanced MRI from January 2019 to June 2020. Patients with various degrees of liver dysfunction were identified with Child-Turcotte-Pugh and albumin-bilirubin grade. Two readers measured the precontrast and PVP signal intensities of liver parenchyma, portal vein, spleen, and psoas muscle. Relative liver enhancement, liver-to-spleen contrast index, portal vein image contrast, and portal vein-to-liver contrast were calculated.

RESULTS

The relative enhancement of liver parenchyma was significantly lower for the Gd-EOB-DTPA group in any degree of liver function than the Gd- DTPA group in the PVP. The Gd-EOB-DTPA group showed significantly lower portal vein-to-liver contrast in the overall study population, CTP class B, and ALBI grade 2 patients compared to the group of Gd-DTPA at PVP. No significant difference was noted in the portal vein image contrast between the two contrast agents, regardless of CTP and ALBI grading.

CONCLUSION

In CLD patients, Gd-EOB-DTPA yielded lower liver parenchymal enhancement and similar portal vein image contrast compared to Gd-DTPA in the PVP. Portal vein-to-liver contrast in the Gd-EOB-DTPA group was lower in the CTP class B and ALBI grade 2 subgroups compared to the Gd- DTPA group.

Abnormal liver function in children hospitalized with acute respiratory infection of adenoviruses: a retrospective study

Human adenoviruses (HAdVs) can cause acute hepatitis in immunocompromised patients. However, it is unclear whether HAdVs are contributors to hepatitis in immunocompetent children. In this study, the liver function test (LFT) results were retrospectively analyzed among children hospitalized (age <14 years) between January 2016 and October 2019 for acute respiratory infection caused by adenoviruses. Alanine transaminase (ALT) and aspartate aminotransferase (AST) levels were elevated in 7.74% and 46.89% of patients, respectively. All patients with >2 folds of the upper limit of ALT or AST levels were infected with HAdV-7 or HAdV-55. Significantly higher levels of ALT, AST, γ-glutamyl transpeptidase (γ-GT), and lower albumin levels were observed in the HAdV-7 infection group than in the HAdV-3 infection group. HAdV-55 infection led to significantly higher γ-GT, total bilirubin, and direct bilirubin levels than the other infection types. The records of four patients with serial monitoring of the LFT results were further analyzed. Multiple indicators remained abnormal during the entire hospitalization in these patients. These results indicate that HAdV infection is often accompanied by abnormal liver function, and HAdV-7 and HAdV-55 might be under-recognized contributors to hepatitis among children.

The effects of low-fat dairy products fortified with 1500 IU vitamin D3 on serum liver function biomarkers in adults with abdominal obesity: a randomized controlled trial

INTRODUCTION

Vitamin D deficiency has been reported to affect liver function biomarkers. This study was aimed to investigate the effect of consuming vitamin D fortified low-fat dairy products on liver function tests in adults with abdominal obesity.

METHODS

This total blinded randomized controlled trial was undertaken on otherwise healthy abdominally obese adults living in Mashhad, Iran. Milk and yogurt were fortified with 1500 IU vitamin D3 nano-capsules. Participants were randomized to receive fortified milk (n = 73), plain milk (n = 73), fortified yogurt (n = 69), and plain yogurt (n = 74) for 10 weeks. Blood samples were taken at baseline and at the end of the study to assess serum levels of vitamin D, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase (ALP), and Gamma glutamyl transferase.

RESULTS

A total of 289 participants completed the study (54% female). The groups were homogenous in terms of age, sex, weight, energy intake, and physical activity level (p-value > 0.05). After the trial, vitamin D serum levels were significantly increased in both groups receiving fortified products (both p < 0.001). There was a significant time*group effect only in serum ALP (p < 0.001).

CONCLUSION

Consumption of dairy products fortified by 1500 IU vitamin D3 might have detrimental effects on serum levels of some liver enzymes in individuals with abdominal obesity. Further studies needed to determine these effects and underlying mechanisms.

TRIAL REGISTRATION

IRCT20101130005280N27 .

Abnormal liver function in children hospitalized with acute respiratory infection of adenoviruses: a retrospective study

Human adenoviruses (HAdVs) can cause acute hepatitis in immunocompromised patients. However, it is unclear whether HAdVs are contributors to hepatitis in immunocompetent children. In this study, the liver function test (LFT) results were retrospectively analyzed among children hospitalized (age < 14 years) between January 2016 and October 2019 for acute respiratory infection caused by adenoviruses. Alanine transaminase (ALT) and aspartate aminotransferase (AST) levels were elevated in 7.74% and 46.89% of patients, respectively. All patients with > 2 folds of the upper limit of ALT or AST levels were infected with HAdV-7 or HAdV-55. Significantly higher levels of ALT, AST, γ-glutamyl transpeptidase (γ-GT), and lower albumin levels were observed in the HAdV-7 infection group than in the HAdV-3 infection group. HAdV-55 infection led to significantly higher γ-GT, total bilirubin, and direct bilirubin levels than the other infection types. The records of four patients with serial monitoring of the LFT results were further analyzed. Multiple indicators remained abnormal during the entirehospitalization in these patients. These results indicate that HAdV infection is often accompanied by abnormal liver function, and HAdV-7 and HAdV-55 might be under-recognized contributors to hepatitis among children.

Fib-4 score is able to predict intra-hospital mortality in 4 different SARS-COV2 waves

Increased values of the FIB-4 index appear to be associated with poor clinical outcomes in COVID-19 patients. This study aimed to develop and validate predictive mortality models, using data upon admission of hospitalized patients in four COVID-19 waves between March 2020 and January 2022. A single-center cohort study was performed on consecutive adult patients with Covid-19 admitted at the Fondazione Policlinico Gemelli IRCCS (Rome, Italy). Artificial intelligence and big data processing were used to retrieve data. Patients and clinical characteristics of patients with available FIB-4 data derived from the Gemelli Generator Real World Data (G2 RWD) were used to develop predictive mortality models during the four waves of the COVID-19 pandemic. A logistic regression model was applied to the training and test set (75%:25%). The model's performance was assessed by receiver operating characteristic (ROC) curves. A total of 4936 patients were included. Hypertension (38.4%), cancer (12.15%) and diabetes (16.3%) were the most common comorbidities. 23.9% of patients were admitted to ICU, and 12.6% had mechanical ventilation. During the study period, 762 patients (15.4%) died. We developed a multivariable logistic regression model on patient data from all waves, which showed that the FIB-4 score > 2.53 was associated with increased mortality risk (OR = 4.53, 95% CI 2.83-7.25; p ≤ 0.001). These data may be useful in the risk stratification at the admission of hospitalized patients with COVID-19.

Liver function test indices-based prediction model for post-stroke depression: a multicenter, retrospective study

BACKGROUND

Post-stroke depression (PSD) was one of the most prevalent and serious neuropsychiatric effects after stroke. Nevertheless, the association between liver function test indices and PSD remains elusive, and there is a lack of effective prediction tools. The purpose of this study was to explore the relationship between the liver function test indices and PSD, and construct a prediction model for PSD.

METHODS

All patients were selected from seven medical institutions of Chongqing Medical University from 2015 to 2021. Variables including demographic characteristics and liver function test indices were collected from the hospital electronic medical record system. Univariate analysis, least absolute shrinkage and selection operator (LASSO) and logistic regression analysis were used to screen the predictors. Subsequently, logistic regression, random forest (RF), extreme gradient boosting (XGBoost), gradient boosting decision tree (GBDT), categorical boosting (CatBoost) and support vector machine (SVM) were adopted to build the prediction model. Furthermore, a series of evaluation indicators such as area under curve (AUC), sensitivity, specificity, F1 were used to assess the performance of the prediction model.

RESULTS

A total of 464 PSD and 1621 stroke patients met the inclusion criteria. Six liver function test items, namely AST, ALT, TBA, TBil, TP, ALB/GLB, were closely associated with PSD, and included for the construction of the prediction model. In the test set, logistic regression model owns the AUC of 0.697. Compared with the other four machine learning models, the GBDT model has the best predictive performance (F1 = 0.498, AUC = 0.761) and was chosen to establish the prediction tool.

CONCLUSIONS

The prediction model constructed using these six predictors with GBDT algorithm displayed a promising prediction ability, which could be used for the participating hospital units or individuals by mobile phone or computer.

A study to evaluate the hepatoprotective effect of N- acetylcysteine on anti tuberculosis drug induced hepatotoxicity and quality of life

BACKGROUND

Drug induced liver injury (DILI) is a serious adverse effect caused by first-line anti-TB (ATT) drugs, limiting the TB-treatment. The tissue inflammation induced by free radical burst and poor dietary intake in TB induces oxidative stress, which was proposed as one of the mechanisms responsible for ATT induced DILI. N-acetylcysteine (NAC) exerts a hepato-protective effect by enhancing the cellular antioxidant defense mechanism. There are few studies evaluating the effect of NAC on ATT induced DILI in Indian-population.

METHODS

This is a prospective, randomized, double-blind, placebo-controlled, parallel-group study. Thirty-eight newly diagnosed TB patients on first-line ATT with normal liver function test (LFT) were recruited and randomized to receive either NAC 600 mg tablet or placebo twice daily for 4 weeks and followed-up for next 4 weeks. LFT [AST, ALT, ALP and Total bilirubin] was assessed at baseline, 2, 4 and 8 weeks. Oxidative-stress biomarkers [Malondialdehyde (MDA), Nitric Oxide (NO), Glutathione (GSH)] and quality of life (QOL) by SF-36 questionnaire were assessed at baseline, 4 and 8 weeks. Adverse Drug Reactions (ADRs) were monitored at every visit. Compliance was assessed by pill-count method.

RESULTS

Baseline characteristics were homogenous among both the groups. In the NAC group, there was significant reduction in ALT (p < 0.01), ALP (p < 0.01), total bilirubin (p < 0.001) at 4 weeks compared to baseline. AST, MDA and NO showed a reduction of 19%, 21.6% and 5.5% respectively from baseline and GSH at showed an increase of 2.6% from baseline at 4 weeks in the NAC group, however these were not statistically significant. These effects in LFT and oxidative biomarkers persisted even at the end of 8 weeks. Significant improvement from baseline in QOL was observed in both the groups (p < 0.05). Between group analysis showed, significant reduction in ALT (p < 0.05) and AST (p < 0.05) in NAC group at 4 weeks, whereas bilirubin, MDA, NO and GSH showed improvement at 4 weeks compared to placebo in NAC group, however it was not statistically significant. This improvement in the LFT and oxidative biomarkers continued even at the end of 8 weeks. Itching and rashes were the most common ADRs, with similar incidence in both the groups. Compliance to treatment was good in both the groups.

CONCLUSION

Significant improvement in liver function parameters is suggestive of hepatoprotective effect of NAC. This observed effect at 4 weeks was found to be persistent at 8 weeks, which signifies prolonged hepato-protective effect of NAC. Long duration studies with large sample size are required for further confirmation of hepato-protective action of NAC.

Breath Biopsy® to Identify Exhaled Volatile Organic Compounds Biomarkers for Liver Cirrhosis Detection

Background and Aims

The prevalence of chronic liver disease in adults exceeds 30% in some countries and there is significant interest in developing tests and treatments to help control disease progression and reduce healthcare burden. Breath is a rich sampling matrix that offers non-invasive solutions suitable for early-stage detection and disease monitoring. Having previously investigated targeted analysis of a single biomarker, here we investigated a multiparametric approach to breath testing that would provide more robust and reliable results for clinical use.

Methods

To identify candidate biomarkers we compared 46 breath samples from cirrhosis patients and 42 from controls. Collection and analysis used Breath Biopsy OMNI™, maximizing signal and contrast to background to provide high confidence biomarker detection based upon gas chromatography mass spectrometry (GC-MS). Blank samples were also analyzed to provide detailed information on background volatile organic compounds (VOCs) levels.

Results

A set of 29 breath VOCs differed significantly between cirrhosis and controls. A classification model based on these VOCs had an area under the curve (AUC) of 0.95±0.04 in cross-validated test sets. The seven best performing VOCs were sufficient to maximize classification performance. A subset of 11 VOCs was correlated with blood metrics of liver function (bilirubin, albumin, prothrombin time) and separated patients by cirrhosis severity using principal component analysis.

Conclusions

A set of seven VOCs consisting of previously reported and novel candidates show promise as a panel for liver disease detection and monitoring, showing correlation to disease severity and serum biomarkers at late stage.

COVID-19 and severity of liver diseases: Possible crosstalk and clinical implications

COVID-19-infected individuals and those who recovered from the infection have been demonstrated to have elevated liver enzymes or abnormal liver biochemistries, particularly with preexisting liver diseases, liver metabolic disorders, viral hepatitis, and other hepatic comorbidities. However, possible crosstalk and intricate interplay between COVID-19 and liver disease severity are still elusive, and the available data are murky and confined. Similarly, the syndemic of other blood-borne infectious diseases, chemical-induced liver injuries, and chronic hepatic diseases continued to take lives while showing signs of worsening due to the COVID-19 crisis. Moreover, the pandemic is not over yet and is transitioning to becoming an epidemic in recent years; hence, monitoring liver function tests (LFTs) and assessing hepatic consequences of COVID-19 in patients with or without liver illnesses would be of paramount interest. This pragmatic review explores the correlations between COVID-19 and liver disease severity based on abnormal liver biochemistries and other possible mechanisms in individuals of all ages from the emergence of the COVID-19 pandemic to the post-pandemic period. The review also alludes to clinical perspectives of such interactions to curb overlapping hepatic diseases in people who recovered from the infection or living with long COVID-19.

Multicenter study of some liver and heart function tests in SARS-Cov-2 patients from three ethnic groups in Iran

The liver and cardiovascular system disorders are not common in COVID-19 patients, but the patients suffering from these complications are exposed to a higher rate of mortality and disease progression. Hepatic injuries can drive to increased levels of liver enzymes, including ALT, AST, and LDH. Abundant levels of AST, LDH, and CPK can be indicators of cardiac injuries. The current study comparise 366 individuals who are divided into COVID-19 patients and healthy individuals groups, in which we have examined hepatic and cardiac function parameters. Moreover, the clinical characteristics of the participants, ethnicities, and their difference with studied parameters were assessed. The results showed Fars individuals are more susceptible to the disease progression, including liver and heart damage. COVID-19 infection is associated with aging, which indicates that the mean age of the case group is ten years older than the control group (P < 0.001). The blood sugar in the case group (140.50) was higher than in the control group (131.66), although there was no difference between the infection and BS (P = 0.505). Similarly, the increased- mean of the ALT level in the case group (102.369) compared with the control group (68.324) resulted in no significant difference (P = 0.318). Other parameters, including CPK, LDH, and AST showed an increase in the control group values compared to the case group; however, the differences were not significant (P = 0.264, P = 0.795, P = 0.417). Considering the involvement of cardiac and hepatic organs by SARS-CoV-2, paying particular attention to the disorders of these organs through assessing the hepatic and cardiac function parameters can enhance the patient's recovery and survival. However, in this study, we not observed significant differences, except for the Fars people. There is need for further assessment of this issue.

Optimal laboratory testing protocol for patients with acne taking oral isotretinoin

BACKGROUND

Isotretinoin is a widely prescribed drug for various dermatological conditions, especially acne. Blood tests are routinely performed to monitor its side effects. However, the optimal testing schedule remains controversial.

AIM

To evaluate the laboratory monitoring tests and schedules of patients with acne taking isotretinoin to determine the most efficient testing regimen.

METHODS

We retrospectively reviewed electronic medical records from the Dermatology Department of Dongguk University Ilsan Hospital from 2005 to 2020 for patients prescribed isotretinoin for acne who underwent monthly blood tests.

RESULTS

Aspartate aminotransferase (AST), alanine aminotransferase (ALT), and triglyceride (TG) levels significantly changed between 5 and 6 mo when the total prescription period and dose variables were considered altogether. The high-density lipoprotein level also significantly changed between 5 and 6 mo. However, low-density lipoprotein (LDL) and total cholesterol levels significantly changed between 1 and 2 mo.

CONCLUSION

We recommend testing AST, ALT, and TG levels once every 5 to 6 mo. We also suggest testing LDL and total cholesterol levels during the first and second months.

A paper-based point-of-care testing device for the colourimetric estimation of bilirubin in blood sample

A paper-based colourimetric assay for the Point-of-Care Testing (PoCT) of bilirubin has been developed based on the formation of a green-coloured copper-bilirubin complex from a blue-coloured tetraamminecopper(II) sulphate complex. The reaction was studied and optimized by UV-Visible absorption spectroscopy and translated onto a paper strip. Hydrophobic circular well patterns on Whatman chromatography paper were created by wax printing. The tetraamminecopper(II) sulphate complex was drop cast and dried on the reagent zones in the wax-patterned paper. The images of reagent zones captured using a scanner were analyzed using ImageJ software. Bilirubin spiked blood serum was tested in the concentration range of 1.2 to 950 µM. The PAD exhibited sensitivities of 0.4197 a.u/μM and 0.1040 a.u/μM for concentration ranges of bilirubin 1.2 to 96 μM and 105 to 950 μM respectively and a low detection limit of 0.799 µM. The method is highly selective to bilirubin, even in the presence of other biomarkers in serum. A plasma separation membrane incorporated PAD was fabricated for the final testing and quantification of bilirubin from whole blood.

Liver dysfunction-related COVID-19: A narrative review

The coronavirus 2019 disease (COVID-19) is caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2. This disease was designated by the World Health Organization as a pandemic on March 11, 2020, which is not seen before. There are no classical features among the cases of the disease owing to the involvement of nearly all body tissues by the virus. Hepatic involvement is one of the characteristics of the COVID-19 course. There are six possible mechanisms of such involvement: Direct virus injury, drug-induced effect, inflammatory cytokine storm, hypoxia-ischemic destruction, abnormalities in liver function tests, and pre-existing chronic liver diseases. Liver abnormalities are seen commonly in the severe or critical stage of COVID-19. Therefore, these abnormalities determine the COVID-19 severity and carry a high rate of morbidity and mortality. The elderly and patients with comorbidities like diabetes mellitus and hypertension are more vulnerable to liver involvement. Another issue that needs to be disclosed is the liver manifestations following the COVID-19 vaccination, such as autoimmune hepatitis. Of note, complete vaccination with third and fourth booster doses is necessary for patients with previous chronic liver diseases or those who have been subjected to liver transplantation. This review aims to explore the various aspects of liver dysfunction during the COVID-19 course regarding the epidemiological features, predisposing factors, pathophysiological mechanisms, hepatic manifestations due to COVID-19 or following vaccination, role of liver function tests in the assessment of COVID-19 severity, adverse effects of the therapeutic agents for the disease, and prognosis.

Autoimmune liver diseases in systemic rheumatic diseases

Systemic rheumatic diseases (SRDs) are chronic, inflammatory, autoimmune disorders with the presence of autoantibodies that may affect any organ or system. Liver dysfunction in SRDs can be associated with prescribed drugs, viral hepatitis, alternative hepatic comorbidities and coexisting autoimmune liver diseases (AILDs), requiring an exclusion of secondary conditions before considering liver involvement. The patterns of overlap diseases depend predominantly on genetic determinants with common susceptible loci widely distributing in both disorders. In AILDs, it is important to identify the overlapping SRDs at an early stage since such a coexistence may influence the disease course and prognosis. Commonly co-occurring SRDs in AILDs are Sjögren syndrome (SS), rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE) in autoimmune hepatitis (AIH), and SS, RA or systemic sclerosis in primary biliary cholangitis. Owing to different disease complications and therapies, it is imperative to differentiate between SLE liver involvement and SLE-AIH overlap disease. Therapeutic options can be personalized to control coexisting conditions of liver autoimmunity and rheumatic manifestations in AILD-SRD overlap diseases. The collaboration between hepatologists and rheumatologists can lead to significant advances in managing such a complex scenario. In this review, we provide a comprehensive overview on coexisting AILDs in different SRDs and the therapeutic approach in managing these overlap diseases.

Postoperative liver function tests can predict anastomotic dysfunction after bile duct injury repair

Liver function tests help in the follow-up of postoperative patients with iatrogenic bile duct injury. There is not clear evidence regarding their predictive role on anastomosis dysfunction. We describe our experience with postoperative liver function tests and a predictive model of long-term patency after repair. This is retrospective cohort study of patients with bilioenteric anastomosis for bile duct injury and their long-term follow-up. A binomial logistic regression model was performed to ascertain the effects of the grade of bile duct injury and liver function test in the postoperative period. A total of 329 patients were considered for the analysis. In the logistic regression model two predictor variables were statistically significant for anastomosis stenosis: type of bilioenteric anastomosis and alkaline phosphatase levels. A ROC curve analysis was made for alkaline phosphatase with an area under the curve of 0.758 (95% CI 0.67-0.84). A threshold of 323 mg/dL was established (OR 6.0, 95% CI 2.60-13.83) with a sensitivity of 75%, specificity of 67%, PPV of 20%, NPV of 96%, PLR of 2.27 and NLR of 0.37. Increased alkaline phosphatase (above 323 mg/dL) after the fourth operative week was found to be a predictor of long-term dysfunction.

Feasibility of liver stiffness measured using two-dimensional shear wave elastography in assessing preoperative liver function for patients with hepatocellular carcinoma

OBJECTIVES

To evaluate the feasibility of liver stiffness (LS) measured using two-dimensional shear wave elastography (2D SWE) in assessing preoperative liver function for patients with hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

A total of 143 patients who underwent surgical resection for HCC between August 2018 and December 2019 were enrolled prospectively. LS measurement, liver function tests including serum biochemical indicators, and indocyanine green (ICG) clearance test were performed preoperatively. Child-Pugh (CP) score, Albumin-bilirubin (ALBI) score and Model for End-Stage Liver Disease score were calculated. ICG retention rate at 15 min (ICG R15) and ICG elimination rate constant (ICG K) were determined automatically. Fibrosis stage was determined based on pathological findings. The association between LS and serum biochemical indicators, liver function scores, and the ICG results were analyzed.

RESULTS

Weak to moderate correlations were identified between LS and biochemical indicators of liver function (all p < 0.01). Weak correlation was identified between LS and CP score, and between LS and ALBI score (all p < 0.001). Moderate correlation was identified between LS and ICG R15 (Pearson r = 0.62, p < 0.001), and between LS and ICG K value (Pearson r =  - 0.49, p < 0.001). The best cutoff of LS to discriminate a normal ICG R15 was 10.6 kPa, with area under the curve (AUC), sensitivity, specificity of 0.874, 0.900 and 0.724, respectively.

CONCLUSIONS

LS determined using 2D SWE could be a potential tool for the preoperative evaluation of liver function in patients with HCC.

Liver Biopsy in Pregnancy: Two Case Reports and Review of the Literature

The etiology of most cases of liver diseases in pregnancy can be diagnosed with a thorough history, physical examination, laboratory values, serology, and noninvasive imaging. However, atypical clinical and laboratory presentations of liver diseases/chemistries require a liver biopsy to render an accurate diagnosis in cases where the biopsy results affect the timing of delivery or impact choice of medical therapy. According to the American College of Gastroenterology, liver biopsy can be effectively and safely conducted in pregnant women. Conventional routes of performing a liver biopsy include the percutaneous, transjugular route, and surgical methods. Endoscopic ultrasound-guided liver biopsy is a recent technique that has not yet gained widespread adoption but can potentially serve as an alternative route for obtaining the liver sample. Adverse events associated with liver biopsy include abdominal pain and hemorrhage. Maternal and fetal outcomes are limited to increased risk of preterm birth and small for gestational age neonate. However, very few studies have formally evaluated the safety of liver biopsy in pregnant women. In this review, we present two successful cases of liver biopsy performed during pregnancy and summarize the most recent evidence regarding the safety and outcomes of the procedure in pregnancy to assist clinicians in their decision to perform a liver biopsy during pregnancy or postpone it until after delivery.

Abnormal liver enzymes: A review for clinicians

Liver biochemical tests are some of the most commonly ordered routine tests in the inpatient and outpatient setting, especially with the automatization of testing in this technological era. These tests include aminotransferases, alkaline phosphatase, gamma-glutamyl transferase, bilirubin, albumin, prothrombin time and international normalized ratio (INR). Abnormal liver biochemical tests can be categorized based on the pattern and the magnitude of aminotransferases elevation. Generally, abnormalities in aminotransferases can be classified into a hepatocellular pattern or cholestatic pattern and can be further sub-classified based on the magnitude of aminotransferase elevation to mild [< 5 × upper limit of normal (ULN)], moderate (> 5-< 15 × ULN) and severe (> 15 × ULN). Hepatocellular pattern causes include but are not limited to; non-alcoholic fatty liver disease/non-alcoholic steatohepatitis, alcohol use, chronic viral hepatitis, liver cirrhosis (variable), autoimmune hepatitis, hemochromatosis, Wilson’s disease, alpha-1 antitrypsin deficiency, celiac disease, medication-induced and ischemic hepatitis. Cholestatic pattern causes include but is not limited to; biliary pathology (obstruction, autoimmune), other conditions with hyperbilirubinemia (conjugated and unconjugated). It is crucial to interpret these commonly ordered tests accurately as appropriate further workup, treatment and referral can greatly benefit the patient due to prompt treatment which can improve the natural history of several of the diseases mentioned and possibly reduce the risk of progression to the liver cirrhosis.

Associations between urinary phthalate metabolite concentrations and markers of liver injury in the US adult population

BACKGROUND

Phthalates have been largely used for years in varieties of products worldwide. However, research on the joint toxic effect of various phthalates exposure on the liver is lacking.

OBJECTIVES

We aimed to assess exposure to phthalates on liver function tests (LFTs).

METHODS

This analysis included data on 6046 adults (≥20 years old) who participated in a National Health and Nutrition Examination Survey (NHANES) in 2007-2016. We employed linear regression and Bayesian kernel machine regression (BKMR), to explore the associations of urinary phthalate metabolites with 8 indicators of LFTs.

RESULTS

Di(2-ethylhexyl) phthalate (ΣDEHP) was found to be positively associated with serum alanine aminotransferase (ALT), gamma-glutamyl transferase (GGT) and alkaline phosphatase (ALP) (all P _FDR < 0.05). We found significant positive associations of ∑DEHP, mono-ethyl phthalate (MEP) and mono-(carboxyisononyl) phthalate (MCNP) with total bilirubin (TBIL) (all P _FDR < 0.05). ΣDEHP, mono-n-butyl phthalate (MBP), mono-(3-carboxypropyl) phthalate (MCPP) and mono-benzyl phthalate (MBzP) were negatively associated with serum ALB (all P _FDR < 0.05). The BKMR analyses showed a significantly positive overall effect on ALT, AST, ALP and TBIL levels with high concentrations of phthalate metabolites and a significantly negative overall effect on ALB and TP, when all the chemicals at low concentrations.

CONCLUSIONS

Our results add novel evidence that exposures to phthalates might be adversely associated with the indicators of LTFs, indicating the potential toxic effect of phthalate exposures on the human liver.

Adherence to clinical follow-up recommendations for liver function tests: A cross-sectional study of patients with HCV and their associated risk behaviors

•

We examined adherence and associated behavioral factors of HCV patients to testing guidelines.

•

Injection drug users were less likely to adhere to physician recommendations.

•

Improved testing adherence requires better patient-provider communication.

This study examined whether patients with Hepatitis C virus (HCV) infection adhered to their physicians’ recommendation and HCV clinical guidelines for obtaining a regular liver function test (LFT), and whether high-risk behaviors are associated with behavioral adherence. A cross-sectional survey was administered to 101 eligible patients with HCV who were recruited from health centers in New Jersey and Washington, DC. Adherence outcomes were defined as the patients’ self-report of two consecutive receipts of LFTs in accordance with their physicians’ recommended interval or the clinical guidelines for a LFT within 3–6 months. 67.4% of patients (66/98) reported a receipt of their physicians’ recommendation for a LFT. The rate of adherence to physician recommendation was about 70% (46/66), however over 50% (52/101) of patients with HCV did not obtain regular LFTs. 15.8% (16/101) of patients continued to use injection drugs. Patients who used injection drugs had 0.87 (adjusted odds ratio (aOR) = 0.13, 95% confidence interval 0.03–0.59) times lower odds adhering to their physician recommendation, relative to non-users. Patients with HIV co-infection had increased odds of adhering to the clinical guidelines (odds ratio 3.41, 95% confidence interval 1.34–8.70) vs. patients who did not report HIV co-infection. Additionally, patients who had received a physician’s recommendation had 7.21 times (95% confidence interval of 2.36–22.2) greater odds adhering to the clinical guidelines than those who had not. Overall, promoting HCV patient-provider communication regarding regular LFTs and reduction of risk behaviors is essential for preventing patients from HCV-related liver disease progression.

Low-level Eexposure to lead dust in unusual work schedules and hematologic, renal, and hepatic parameters

BACKGROUND

Many workers are exposed to lead dust in lead-‑zinc mines. Exposure to this heavy toxic metal and its compounds can cause irreversible adverse health effects.

OBJECTIVE

To assess possible hematotoxic, nephrotoxic, and hepatotoxic potentials of low levels of lead in a group of mine workers exposed to this heavy metal in an unusual work schedule.

METHODS

A total of 73 exposed and 70 non-exposed employees were interviewed. Demographic data, and occupational and medical history of the employees were obtained by questionnaires. Air monitoring was performed to determine the workers' time-weighted average (TWA) exposure to lead dust. The threshold limit value (TLV) for lead was adjusted for unusual work schedules according to the model developed by the University of Montreal and the Institute de Recherche en Sante et en Securite du Travail (IRSST). Blood samples were collected for complete blood count, liver and kidney function tests. Data were analyzed using version 21.0 of the SPSS software.

RESULTS

The TWA exposure of workers was 24 μg/m³. On average, the worker's exposure to lead dust did not exceed the 8-h OSHA and ACGIH TLV-TWA of 50 μg/m³. Significant associations were found only between exposure to lead and platelet count, red cell distribution width, total protein, and albumin.

CONCLUSIONS

Exposure to low levels of lead dust in unusual work schedules was not associated with overt hematotoxicity, hepatotoxicity or nephrotoxicity. However, mild, sub-clinical, pre-pathologic significant changes were noted in some blood parameters of the exposed employees as compared with their referent counterparts.

Heat precondition is a potential strategy to combat hepatic injury triggered by severe heat stress

AIM

Environmental heat stress alters physiological and biochemical functions which leads to multiorgan dysfunction including severe hepatic injury in animals. We hypothesize that heat preconditioning can be potential intervention in combating heat illnesses.

MAIN METHODS

Sprague Dawley rats were exposed to moderate heat stress, severe heat stress and heat preconditioning in heat simulation chamber. Mean arterial pressure, heart rate, skin and core temperature were monitored in pre and post heat exposed animals. After stress exposure, blood for hemodynamic and liver tissue for liver function tests, oxidative stress, inflammatory variables and structural studies were collected from rats. Hepatic mitochondria were isolated to study the key structural alterations and functional changes by transmission electron microscopy.

KEY FINDINGS

The effect of heat precondition shows improvement in time to attain the core temperature, weight loss, blood pressure and heart rate in rats. Results exhibited decreased levels of liver function tests, elevated levels of free radicals and inflammatory cytokines in heat exposed liver as compared with heat preconditioned animals. Expression levels of mitochondrial heat shock protein 60, superoxide dismutase 1 and uncoupling protein 1 along with activity of electron transport chain complexes I-V were examined and found to be increased in heat preconditioned as compared to heat stressed animals. Morphological studies of liver parenchyma demonstrated reduction in structural deterioration of hepatic lobules and restoration of mitochondrial structural integrity in heat preconditioned rats.

SIGNIFICANCE

Present study suggests that heat preconditioning intervention plays a crucial role in protection against heat induced hepatic injury in animals.

[The clinical application of blood routine and liver and kidney function test in COVID-19 disease prediction]

Objective: To explore the clinical application value of routine indicators such as blood routine and liver and kidney function in auxiliary diagnosis and prognosis of COVID-19 patients. Methods: SNK-q and other methods were used to retrospectively analyzed the differences of blood routine test, liver and kidney function and other inflammatory indexes of 30 patients with covid-19, 29 patients with other viral pneumonia, 35 patients with influenza A/B and 25 healthy persons from January 28 to February 14, 2020 in Xiangya Hospital of Central South University. Results: The neutrophils count increased gradually in COVID-19 group, influenza A/B group and other types of viral pneumonia group, and the difference between COVID-19 group and other viral pneumonia groups was statistically significant(H=-19.064,P<0.05); The lymphocyte count decreased gradually in the control group, influenza A/B group, other viral pneumonia group and COVID-19 group. In addition, DB, UA and GLU were also different among groups. Subgroup analysis showed that there were statistically significant differences in N(F=9.581,t=-0.152,P<0.05), N%(F=5.723,t=-0.600, P<0.05), NLR(F=4.773, t=-1.161, P<0.05), PCT(F=17.464, t=-1.477, P<0.05)and CRP(F=7.656, t=-1.973, P<0.05) between patients with lung involvement +-++ and patients with lung involvement +++-++++. There were statistically significant differences in NLR(F=63.931, t=-2.815, P<0.01), AST(F=15.704, t=-1.930, P<0.01), ALT(F=35.551, t=-2.199, P<0.01), LDH(F=7.715, t=-2.703, P<0.05) and GLU(F=6.306, t=-5.116, P<0.05) between the light+common subgroup and the heavy+critical subgroup of COVID-19 clinical classification. Correlation analysis showed that clinical stage and imaging credit period were significantly correlated with NLR (r=0.406, P=0.026; r=0.397, P=0.030), ALT (r=0.403, P=0.049; r=0.418, P=0.047), LDH (r=0.543, P<0.01; r=0.643, P<0.01) and GLU(r=0.750, P<0.01; r=0.471, P=0.042). A total of 5 principal components were extracted from all the included indicators, and the comprehensive information extraction rate was 82.86%. Indicators of a large load included Ur, PCT and CRP in PC1; ALT, AST and GLU in PC2; N%, L%, L and NLR in PC3. It indicated that the indicators of acute infection, liver function and blood routine had certein warning effect on disease surveillance. The results of ROC curve analysis showed that the combined detection of N+TB+Urea was the best practice to distinguish COVID-19 and other viral pneumonia, while the combined detection of N+L+UA was the most effective solution to make a distinction between COVID-19 and influenza A/B patients. In the aspect of disease evaluation, NL+LDH+GLU+ALT combined detection represent the best diagnostic performance to distinguish the clinical stage of light+common type and heavy+critical type, achieving the AUC (ROC) to 0.904, with the sensitivity 75% and the specificity 100% at the cut-off value of 0.477. Conclusion: In addition to etiology and imaging examination, doctors can also improve the routine laboratory tests such as blood routine test, liver and kidney function to assist diagnosis and disease prediction of patients with respiratory tract infection.

Evaluation of Liver Function and the Role of Biliary Drainage before Major Hepatic Resections

Background

Prevention of posthepatectomy liver failure is a prerequisite for improving the postoperative outcome of perihilar cholangiocarcinoma. From this perspective, appropriate assessment of future liver remnant (FLR) function and the optimized preparation are mandatory.

Summary

FLR volume ratio using CT volumetry based on 3-dimensional vascular imaging is the current assessment yardstick and is sufficient for assessing a normal liver. However, in a liver with underling parenchymal disease such as fibrosis or prolonged jaundice, weighing up the degree of liver damage against the FLR volume ratio is necessary to know the real FLR function. For this purpose, the indocyanine green (ICG) clearance test, monoethylglycinexylidide (MEGX) test, liver maximum capacity (LiMAX) test, ^99mTc-labeled galactosyl human serum albumin (^99mTc-GSA) scintigraphy, albumin-bilirubin (ALBI) grade, and ALPlat (albumin × platelets) criterion are used. After the optimization of FLR function by means of portal vein embolization or associating liver partition and PVL (portal vein ligation) for staged hepatectomy (ALPPS), SPECT scintigraphy with either ^99mTc-GSA or ^99mTc-mebrofenin compensates for misestimation due to the regional heterogeneity of liver function. The role of preoperative biliary drainage has long been debated, with the associated complications having led to a lack of approval. However, the recent establishment of safety and an improvement in success rates of endoscopic biliary drainage seem to be changing the awareness of the importance of biliary drainage.

Key Messages

Appropriate selection of an assessment method is of prime importance to predict the FLR function according to the preoperative condition of the liver. Preoperative biliary drainage in patients with perihilar cholangiocarcinoma is gaining support due to the increasing safety and success rate, especially in patients who need optimization of their liver function before hepatectomy.

Pharmacokinetics of tigecycline in critically ill patients with liver failure defined by maximal liver function capacity test (LiMAx)

BACKGROUND

In critically ill patients, tigecycline (TGC) remains an important therapeutic option due to its efficacy against multiresistant Gram-positive and Gram-negative bacteria. TGC is metabolized and eliminated predominantly by the liver. Critical illness-induced liver failure may have a profound impact on the pharmacokinetic of TGC. In the present study, we aimed to establish a link between the degree of liver dysfunction and TGC plasma concentration using the novel maximum liver function capacity (LiMAx) test, as a dynamic liver function test.

MATERIALS/METHODS

The prospective study included 33 patients from a surgical ICU with the clinical indication for antibiotic therapy with TGC. The patients received 100 mg loading dose of TGC followed by intermittent standard doses of 50 mg q12. Blood samples for TGC plasma concentration were collected at 0.3, 2, 5, 8 and 11.5 h in a steady-state condition after at least 36 h post-standard dosage. The results were analyzed by means of a high-performance liquid chromatography (HPLC) method. Within the same day, the LiMAx test was carried out and routine blood parameters were measured.

RESULTS

Peak plasma concentrations of TGC were significantly higher in patients with severe liver failure (LiMAx < 100 µg/kg/h) when compared to patients with normal liver function (LiMAx > 300 µg/kg/h). The pharmacokinetic curves revealed higher values in severe liver failure at any measured point. Moreover, LiMAx and total bilirubin were the only liver-related parameters that correlated with TGC C_max.

CONCLUSIONS

The present study demonstrates a high variability of TGC plasma concentrations in critically ill patients. The results show a significant correlation between the degree of liver dysfunction, measured by the LiMAx test, and TGC C_max. LiMAx test may be a helpful tool beyond others for adjusting the required dosage of hepatic metabolized antibiotics in critically ill patients. Trial registry DRKS-German clinical trials register; Trial registration number: DRKS00008888; Date of registration: 07-17-2015; Date of enrolment of the first participant to the trial: 12-10-2015.

Coronavirus Disease 2019: A Gastroenterologist's Perspective in May 2020

We are in the middle of coronavirus disease 2019 (COVID-19) pandemic which has affected every aspect of human life all over the world. Although COVID-19 primarily affects the lungs, it is in fact a multisystem disorder causing high mortality and panicking the whole world. Gastrointestinal (GI) manifestations of this disorder usually accompany respiratory manifestations and this combination is indicative of the severity of the disease. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA, which causes COVID-19, enters the body by attaching to angiotensin converting enzyme-2 receptors which are not only present in the respiratory tract but also in the GI tract. Person-to-person droplet transmission is the main mode of spread although there is potential for fecal-oral transmission. Patients with inflammatory bowel disease (IBD) are not at increased risk of developing COVID-19 and they should continue to take their current medications. If they become positive for SARS-CoV-2 RNA or COVID-19, their biologic therapy should be either delayed or on hold temporarily. GI endoscopy units are high-risk areas and GI procedures are high-risk procedures for the transmission of SARS-CoV-2 infection. Only emergency and semi-emergency procedures should be done, and elective procedures should be temporarily on hold until adequate resources are available. Endoscopists should use appropriate personal protective equipment. Mildly abnormal liver function tests (LFTs) are common in COVID-19 patients and are mostly due to systemic inflammatory response, hepatic ischemia or hepatotoxic medications. Close monitoring of liver function and supportive care of COVID-19 patients are recommended.

Is testing of aspartate aminotransferase necessary along with every alanine aminotransferase for health check in elderly individuals?

OBJECTIVE

This study is to evaluate whether Aspartate Aminotransferase (AST) is necessary to screen for liver function in apparently healthy elderly individuals.

METHODS

We derived the proportions of elevated ASTs that would not be measured based on 2018-year of paired Chinese elderly (Age ≥ 65 years old) check-up. Defined as AST > 40U/L is elevated. The relationship between alanine aminotransferase (ALT) and AST was analyzed by using Pearson's approach. Receiver operating characteristics curve analysis was used to evaluate the predictive accuracy of ALT for abnormal AST.

RESULTS

52,857 pairs of ALT and AST were analyzed. Serum AST was found to be positively correlated with serum ALT, r = 0.81, p < 0.01 for the entire cohort. The receiver operating characteristics (ROC) curve of ALT for predicting positive AST is 0.918. The optimal threshold for ALT is 28 U/L with the sensitivity of 82.6%, and specificity of 86.8%. At the threshold, below 0.7% of subjects with positive AST were missed, but approximately 83% of the AST tests were eliminated.

CONCLUSION

Our study showed that tests of AST were not necessary along with every ALT test for health check in elderly individuals. An estimated 84.5% of subjects were not needed for AST tests which could have saved about CN¥ 815 million (USD$115 million or EURO$100 million) every year.

Early diagnostic test for acute fatty liver of pregnancy: a retrospective case control study

Background

Early diagnosis is important to lower the mortality rate of acute fatty liver of pregnancy (AFLP). The Swansea criteria is commonly used to diagnose AFLP, but some terms could only be reached when symptoms and signs have progressed, or are not efficient in clinical practice. Therefore, it is necessary to select cost effective tests to simplify and facilitate early suspicion of acute fatty liver of pregnancy.

Methods

This is a retrospective study of 28,800 medical records at the Second Xiangya Hospital from 2009 to 2015, including 41 patients with AFLP and 172 other diseases that could show similar symptoms to AFLP. The evaluated variables included past history of liver diseases, blood pressure, gastrointestinal symptoms, blood count, liver function test, coagulation function test and blood sugar test. The sensitivity, specificity, positive predict value and negative predict value were calculated for models in diagnosing AFLP.

Results

The significant variables associated with AFLP included gastrointestinal symptoms, blood pressure > 140/90 mmHg, aminotransferase> 42 IU/l, total bilirubin> 0.8 mg/dl, total bilirubin acid> 10.0 μmol/L, activated partial prothrombin time(APTT) > 34 s, prothrombin time(PT) > 14 s, white blood cells> 11 *10⁶/l and blood sugar< 72 mg/dl. Gastrointestinal symptoms +aminotransferase +bilirubin +bile acid +APTT/PT showed 97.6% sensitivity and 97.1% specificity to diagnose AFLP. Adding blood pressure, blood sugar or white blood cells decreased the accuracy of the statistical model.

Conclusions

Application of a statistical model including maternal symptoms, biochemical and haematological parameters has high diagnostic accuracy for earlier identification of AFLP. However, this finding needs to be tested in another cohort to determine whether this statistical model has the same performance.

Drug-Induced Liver Injury from Statins

The hydroxymethyglutaryl-coenzyme A reductase inhibitors (statins) are a commonly prescribed class of medication for the treatment of hyperlipidemia and coronary artery disease. This class of medication has several proven benefits, including reduction of mortality related to coronary artery disease. A major consideration when prescribing these drugs are the potential for adverse effects, mainly myalgias, myopathy, and hepatotoxicity. In this article, we summarize current data on statin-associated hepatotoxicity and highlight that the risk of clinically significant idiosyncratic drug-induced liver injury is actually quite small. We also review preclinical data suggesting potential hepatoprotective effects of statin therapy.

Liver and thyroid profile in educating smokeless tobacco users and its role in oral health promotion

BACKGROUND

Smokeless tobacco (SLT) usage contributes about 40% of the total tobacco used in India. Among the 28 known carcinogens in SLT, tobacco-specific nitrosamines are considered to be the most potent. This has challenged the metabolic condition leading to a rise in the inflammatory status, hepatic injury, and apoptosis of the liver and thyroid tissues. Therefore, the present study was undertaken to evaluate the adverse effects of SLT on the liver and thyroid and establish a correlation between them in Jharkhand population.

MATERIALS AND METHODS

A total of 100 individuals (50 SLT users and 50 healthy individuals) were selected for the study. A complete history was obtained, and clinical examination was done to evaluate any oral mucosal changes. Venous blood samples were taken to analyze the liver function test and thyroid profile.

RESULTS

Significant changes were observed in the liver enzyme levels and thyroid profile in SLT users when compared to healthy controls. All the parameters of liver function test had a positive correlation with the form of SLT, whereas thyroid profile had a negative correlation.

CONCLUSION

This study might be helpful in creating awareness on the hazards of using SLT among the Indian population as a despicable substitute to smoking tobacco. It also acts as a diagnostic tool and warning alarm in chronic tobacco users.

Estimating liver function in a large cirrhotic cohort: Signal intensity of gadolinium-ethoxybenzyl-diethylenetriamine penta-acetic acid-enhanced MRI

BACKGROUND

To assess whether gadolinium-ethoxybenzyl-diethylenetriamine penta-acetic acid-enhanced MRI study is useful to estimate liver function in comparison to the presence or absence of cirrhosis, Child Pugh (CP), Model for End-stage Liver Disease (MELD), ALBI scores and biochemical test.

METHODS

We retrospectively reviewed all consecutive Gd-EOB-DTPA-enhanced-MRI studies performed between 2010 and 2016 in patients with focal liver lesions undergoing clinical evaluation. Patients were divided in study and control group according to the presence of cirrhosis, and then classified by CP, MELD and ALBI. Signal intensity was calculated through the liver-to-muscle ratio in portal- (SI-POR) and hepatobiliary-phase(SI-HEP).

RESULTS

Three-hundred-three Gd-EOB-DTPA liver-enhanced-MRI studies were included. One-hundred-ninety-one patients (63%) were cirrhotic. SI-HEP was significantly lower in cirrhotic group (0.55 ± 0.29 vs 0.66 ± 0.40, p = 0.004).The SI-HEP progressively decreased from CP-A to CP-C (0.59 ± 0.28 to 0.25 ± 0.19, p < 0.0001) and a significant difference was found between MELD ≤ 9 and MELD > 9 groups (0.61 ± 0.31 vs 0.49 ± 0.28, p = 0.007). No differences between ALBI grades were evident. Among biochemical parameters a moderate correlation was found among SI-HEP and total bilirubin, AST and albumin.

CONCLUSION

SI-HEP after Gd-EOB-DTPA-enhanced-MRI effectively stratified patients with different Child Pugh grades and MELD scores. This technique could hence be useful as a novel radiological marker to estimate the underlying liver function.

Utility of liver function tests in acute cholecystitis

Backgrounds/Aims

Common bile duct stones (CBDS) affect the management of acute cholecystitis (AC). This study aims to investigate the utility of liver function tests (LFTs) in predicting the presence of CBDS in AC patients.

Methods

Retrospective cohort study of adult patients with AC found in the American College of Surgeons National Surgical Quality Improvement Program database from 2008 to 2016. Patients were classified into two groups, without CBDS (AC⁻) and with CBDS (AC⁺). LFT results namely total bilirubin, SGOT and ALP were collected and categorized into normal and abnormal with the cut-offs of 1.2 mg/dl for total bilirubin, 40 U/L for SGOT and 120 IU/L for ALP. Measures of diagnostic accuracy for individual and combinations of LFTs were computed.

Results

A total of 32,839 patients were included in the study, with 8,801 (26.8%) AC⁺ and 24,038 (73.2%) AC⁻ patients. Their mean age was 52.4 (±18.6) years and over half (59.1%) were females. Mean LFT results were significantly higher in the AC⁺ group for total bilirubin (1.82 vs 0.97), SGOT (110.9 vs 53.3) and ALP (164.4 vs 102.3) (p<0.0001). The proportions of abnomal LFTs were significantly higher in the AC⁺ group for total bilirubin (47.7% vs 20.2%), SGOT (62.8% vs 27.1%) and ALP (56.6% vs 21.0%) (p<0.0001). Among AC⁺, the odds of having abnormal results for bilirubin, SGOT and ALP were found to be 3.61, 4.54 and 4.90 times higher than among AC⁻, respectively.

Conclusions

Abnormal LFTs are strong predictors for the presence of CBDS in patients with AC. Normal LFTs should be interpreted with caution as some patients with AC and CBDS might not present with characteristic abnormalities in results.

C-reactive protein at ICU admission as a marker of early graft dysfunction after liver transplant. A prospective, single-center cohort study

OBJECTIVE

To explore the behavior of C-reactive protein (CRP) after orthotopic liver transplantation (OLT) during the first postoperative days, and its usefulness as a marker of severe early allograft dysfunction (EAD).

DESIGN

A prospective, single-center cohort study was carried out.

SETTING

The Intensive Care Unit (ICU) of a regional hospital with a liver transplant program since 1997.

PATIENTS

The study comprised a total of 183 patients admitted to our ICU immediately after liver transplantation between 2009 and 2015.

VARIABLES OF INTEREST

C-reactive protein levels upon ICU admission and after 24 and 48h, severe EAD and hospital mortality.

RESULTS

The CRP levels after OLT were: upon ICU admission 57.5 (51.6-63.3)mg/L, after 24h 80.1 (72.9-87.3)mg/L and after 48h 69.9 (62.5-77.4)mg/L. Severe EAD patients (14.2%) had higher mortality (23.1 vs 2.5; OR 11.48: 2.98-44.19) and lower CRP upon ICU admission (39.3 [29.8-48.7]mg/L) than the patients without EAD (0.5 [53.9-67.0]; p<0.05] - the best cut-off point being 68mg/L (sensitivity 92.3%; specificity 40.1%; Youden index 0.33). Lower CRP upon ICU admission was correlated to higher mortality (24.5 [9.2-39.7] vs 59.4 [53.4-65.4]; p<0.01, AUC 0.79 [0.65-0.92]).

CONCLUSION

Liver transplant is a strong inflammatory stimulus accompanied by high levels of C-reactive protein. A blunted rise in CRP on the first postoperative day after OLT may be a marker of poor allograft function and is related to hospital mortality.

Prospective Assessment of Liver Function by an Enzymatic Liver Function Test to Estimate Short-Term Survival in Patients with Liver Cirrhosis

BACKGROUND

MELD attempts to objectively predict the risk of mortality of patients with liver cirrhosis and is commonly used to prioritize organ allocation. Despite the usefulness of the MELD, updated metrics could further improve the accuracy of estimates of survival.

AIMS

To assess and compare the prognostic ability of an enzymatic ¹³C-based liver function test (LiMAx) and distinct markers of liver function to predict 3-month mortality of patients with chronic liver failure.

METHODS

We prospectively investigated liver function of 268 chronic liver failure patients without hepatocellular carcinoma. Primary study endpoint was liver-related death within 3 months of follow-up. Prognostic values were calculated using Cox proportional hazards and logistic regression analysis.

RESULTS

The Cox proportional hazard model indicated that LiMAx (p < 0.001) and serum creatinine values (p < 0.001) were the significant parameters independently associated with the risk of liver failure-related death. Logistic regression analysis revealed LiMAx and serum creatinine to be independent predictors of mortality. Areas under the receiver-operating characteristic curves for MELD (0.86 [0.80-0.92]) and for a combined score of LiMAx and serum creatinine (0.83 [0.76-0.90]) were comparable.

CONCLUSIONS

Apart from serum creatinine levels, enzymatic liver function measured by LiMAx was found to be an independent predictor of short-term mortality risk in patients with liver cirrhosis. A risk score combining both determinants allows reliable prediction of short-term prognosis considering actual organ function. Trial Registration Number (German Clinical Trials Register) # DRKS00000614.

Use of combined laboratory and ultrasonography results to select patients for biliary tract imaging or intervention: a retrospective cohort study

AIM

To determine whether combined laboratory and ultrasonography results can be used to select patients for biliary tract imaging (BTI) or intervention.

BACKGROUND

Despite ongoing research, selection of patients with suspected CBD stone (CBDS) for BTI or direct intervention without imaging is still a subject of debate.

METHODS

Patients aged≥18 with symptomatic gallstone disease (SGD) who underwent MRCP over 3 years (2014-2017) were divided into the following cohorts: Group A: Normal liver enzymes with normal CBD diameter; Group B: Normal liver enzymes with dilated CBD; Group C: Isolated rise of liver enzymes with normal CBD diameter; Group D: Isolated rise of liver enzymes with dilated CBD; Group E: Hyperbilirubinemia with normal CBD diameter; Group F: Hyperbilirubinemia with dilated CBD. Binary logistic regression models were constructed for analyses.

RESULTS

Overall, 1022 patients were included. The frequency of CBDS was 7.2% in Group A; 3.8% in Group B; 6.3% in Group C; 22% in Group D; 24.2% in Group E; 47.4% in Group F. Hyperbilirubinemia with normal CBD (OR:1.52,P=0.010) and hyperbilirubinemia with dilated CBD (OR:5.12,P<0.001) independently predicted CBDS. Normal or isolated rise of liver enzymes with or without dilated CBD did not predict CBDS. Combined laboratory and ultrasonography had positive predictive value and negative predictive value of up to 47.37% and 100%, respectively.

CONCLUSION

Patients with isolated rise of liver enzymes or hyperbilirubinemia with or without dilated CBD should undergo BTI prior to ERCP. Direct ERCP could be preserved for patients with high suspicion of CBDS where clinical features do not allow waiting for BTI.

Ribavirin in Acute Hepatitis E Infection in Patients with Gynecological Cancer: A Case Series

Hepatitis E virus infection is usually a self-limited disease. However, during the last years there has been growing evidence for prolonged and chronic infection occurring in patients with immunosuppression. Also patients with malignant and rheumatic diseases have been identified to be at risk for chronic hepatitis E. However, their course and prognosis are not well characterized and there have been no reports of hepatitis E virus infection in patients with gynecological cancer. Here, we report three Caucasian females with breast and ovarian cancers presenting with elevation of aminotransferase levels during anticancer treatment. Although only few or no clinical hints suggested hepatitis E virus infection, the diagnosis of hepatitis E virus infection was confirmed by seroconversion, which might occur with some delay, and/or by polymerase chain reaction. While two patients had a self-limited course, the third patient with a high-risk oncological constellation required ribavirin in order to resume chemotherapy. These cases highlight the need for hepatitis E virus testing in patients with gynecological cancer and elevated aminotransferase levels. Further, these cases show that in selected high-risk patients, ribavirin treatment may be necessary based on the decision of a multidisciplinary team.

Preoperative laboratory data are associated with complications and surgical site infection in composite head and neck surgical resections

OBJECTIVES

1) Describe normal/abnormal preoperative laboratory testing incidence in head and neck (H&N) composite resections and 2) determine complication, surgical site infection (SSI), and transfusion predictors by laboratory test.

METHODS

The 2006 to 2013 NSQIP databases were queried for H&N composite resections. Laboratory data was categorized within, under, or above the normal reference range according to NSQIP definitions. Overall complications and SSI were analyzed with multivariable logistic regression analysis.

RESULTS

From 2006 to 2013, there were 1193H&N composite resections, of which 1135 (95.1%) underwent ≥1 preoperative laboratory test. Complete blood counts were obtained in 92.3%, basic metabolic panels in 90.7%, coagulation studies in 56.2%, and liver function tests (LFTs) in 52.6%. Low sodium was found in 11.5%, increasing complication odds by 2.30 (p = 0.005). High AST comprised 10.0% and increased complication odds (OR = 2.93, p = 0.012). Additionally, 9.2% had a high white blood cell (WBC) count and 3.5% had high platelets, increasing complications by 1.92 (p = 0.030) and 3.13 (p = 0.015), respectively. BUN, creatinine, total bilirubin, albumin, alkaline phosphatase, INR, PT, and aPTT abnormal values did not affect postoperative complications. Increased SSI odds were appreciated with low sodium (OR: 2.83, p = 0.002), high AST (OR: 6.85, p < 0.001), and high alkaline phosphatase (OR: 5.46, p = 0.007). Importantly, INR had no effect on transfusion rates. High PT, aPTT, or low platelets did not change transfusion odds.

CONCLUSION

Inflammatory markers are associated with complications but not SSI. High LFTs and low sodium are associated with complications and SSI. Coagulopathies did not increase transfusion rates. These findings identify laboratory studies to focus on during H&N resection preoperative assessments.

Development and validation of a predictor of insufficient enhancement during the hepatobiliary phase of Gd-EOB-DTPA-enhanced magnetic resonance imaging

Background Insufficient enhancement of liver parenchyma negatively affects diagnostic accuracy of Gd-EOB-DTPA-enhanced magnetic resonance imaging (MRI). Currently, there is no reliable method for predicting insufficient enhancement during the hepatobiliary phase (HBP) in Gd-EOB-DTPA-enhanced MRI. Purpose To develop a predictor for insufficient enhancement of liver parenchyma during HBP in Gd-EOB-DTPA-enhanced MRI. Material and Methods In order to formulate a HBP enhancement test (HBP-ET), clinical factors associated with relative enhancement ratio (RER) of liver parenchyma were retrospectively determined from the datasets of 156 patients (Development group) who underwent Gd-EOB-DTPA-enhanced MRI between November 2012 and May 2015. The independent clinical factors were identified by Pearson's correlation and multiple stepwise regression analysis; the performance of HBP-ET was compared to Child-Pugh score (CPS), Model for End-stage Liver Disease score (MELD), and total bilirubin (TBIL) using receiver operating characteristic (ROC) curve analysis. The datasets of 52 patients (Validation group), which were examined between June 2015 and Oct 2015, were applied to validate the HBP-ET. Results Six biochemical parameters independently influenced RER and were used to develop HBP-ET. The mean HBP-ET score of patients with insufficient enhancement was significantly higher than that of patients with sufficient enhancement ( P < 0.001) in both the Development and Validation groups. HBP-ET (area under the curve [AUC] = 0.895) had better performance in predicting insufficient enhancement than CPS (AUC = 0.707), MELD (AUC = 0.798), and TBIL (AUC = 0.729). Conclusion The HBP-ET is more accurate than routine indicators in predicting insufficient enhancement during HBP, which is valuable to aid clinical decisions.

Toxicological evaluation of the aqueous whole plant extract of Aerva lanata (l.) Juss. ex Schult (Amaranthaceae)

ETHNOPHARMACOLOGICAL RELEVANCE

Aerva lanata (L.) of the family Amaranthaceae is a Nigerian medicinal plant used traditionally for the management of lithiasis, headache, renal disorder, haematemesis, bronchitis, nasal bleeding, cough, scorpion stings, fractures and spermatorrhoea. Studies that show the pharmacological basis for some of such uses have been reported. There is, however, no scientific report on its toxicity profile to the best of our knowledge.

AIM OF THE STUDY

This study was therefore aimed at investigating the toxicity profile of the aqueous extract of Aerva lanata.

MATERIALS AND METHODS

Acute toxicity tests for the extract administered orally at 1-30g/kg and intraperitoneally at 0.1-2g/kg were carried out in albino mice; while a sub-chronic toxicity test was done by daily oral administration of the extract at 40-1000mg/kg to albino rats for 90 days. Anthropometric, biochemical and haematological parameters' assessments as well as vital organs histological examinations were performed in the sub-chronic toxicity study.

RESULTS

The LD₅₀ of the extract for oral and intraperitoneal acute toxicity tests were 22.62g/kg and 0.432g/kg respectively. The extract produced apparent changes in body weights of both male and female rats and significantly (p < 0.05) increased the weights of lungs, brain and pancreas of female rats while reducing the weight of testes in male rats. Haematological parameters were also altered with total leukocytes significantly (p < 0.05) increased and platelets significantly (p < 0.05) reduced in female rats; while neutrophils significantly (p < 0.05) increased in male rats. The extract (40-1000mg/kg) produced significant (p < 0.05) reduction of serum alanine transaminase concentration in both male and female rats. Aspartate transaminases and albumin were also significantly (p < 0.05) reduced in both male (at 1000mg/kg) and female (at 200mg/kg) rats. Alkaline phosphatase was also significantly (p < 0.05) reduced in female rats at 200mg/kg of the extract. Substantial alterations of creatinine, urea and uric acid were also observed. Triglyceride and cholesterol concentrations were significantly increased in male rats but decreased in female rats. At 1000mg/kg, the extract significantly elevated catalase and superoxide dismutase levels with no effect on malondialdehyde levels. It also reduced sperm count and motility of male rats. Mild to moderate cellular changes in the brain, kidney, liver, lungs, spleen and testes of treated rats were observed on histological examinations. Significant changes in biochemical and haematological parameters were also noted in treated animals when compared to control animals 30 days after cessation of treatment.

CONCLUSION

The overall findings of this study suggest that the aqueous extract of A. lanata is relatively safe on acute oral exposure, moderately toxic on acute intraperitoneal administration and is relatively safe with antioxidant actions on prolonged exposure. It however shows potentials for toxic effects such as cellular damage to organs, dyslipidaemia and reduction in male reproductive capacity. Caution must therefore be applied in its use on a long term basis.

Linezolid in liver failure: exploring the value of the maximal liver function capacity (LiMAx) test in a pharmacokinetic pilot study

Patients in the intensive care unit frequently require antibiotic treatment. Liver impairment poses substantial challenges for dose selection in these patients. The aim of the present pilot study was to assess the novel maximal liver function capacity (LiMAx test) in comparison with conventional liver function markers as covariates of drug clearance in liver failure using linezolid as a model drug. A total of 28 patients with different degrees of liver failure were recruited. LiMAx test as well as plasma, dialysate and urine sampling were performed under linezolid steady-state therapy (600 mg twice daily). NONMEM^® was used for a pharmacometric analysis in which the different clearance routes of linezolid were elucidated. Linezolid pharmacokinetics was highly variable in patients with liver failure. The LiMAx score displayed the strongest association with non-renal clearance (CL_non-renal) [ = 4.46∙(body weight/57.9) ^0.75∙(LiMAx/221.5)^0.388 L/h], which reduced interindividual variability in CL_non-renal from 46.6% to 33.6%, thereby being superior to other common markers of liver function (international normalised ratio, gamma-glutaryl transferase, bilirubin, thrombocytes, alanine aminotransferase, aspartate aminotransferase). For LiMAx < 100 µg/kg/h, 64% of linezolid trough concentrations were above the recommended trough concentration of 8 mg/L, indicating the necessity of therapeutic drug monitoring in these patients. This is the first pilot application of the LiMAx test in a pharmacokinetic (PK) study demonstrating its potential to explain PK variability in linezolid clearance. Further studies with a larger patient collective and further drugs are highly warranted to guide dosing in patients with severe liver impairment.

Blood mercury concentrations are associated with decline in liver function in an elderly population: a panel study

BACKGROUND

Mercury is a toxic heavy metal and is known to affect many diseases. However, few studies have examined the effects of mercury exposure on liver function in the general population. We examined the association between blood mercury concentrations and liver enzyme levels in the elderly.

METHODS

We included 560 elderly participants (60 years or older) who were recruited from 2008 to 2010 and followed up to 2014. Subjects visited a community welfare center and underwent a medical examination and measurement of mercury levels up to five times. Analyses using generalized estimating equations model were performed after adjusting for age, sex, education, overweight, alcohol consumption, smoking, regular exercise, high-density lipoproteins cholesterol, and total calorie intake. Additionally, we estimated interaction effects of alcohol consumption with mercury and mediation effect of oxidative stress in the relationship between mercury levels and liver function.

RESULTS

The geometric mean (95% confidence interval (CI)) of blood mercury concentrations was 2.81 μg/L (2.73, 2.89). Significant relationships were observed between blood mercury concentrations and the level of liver enzymes, including aspartate aminotransferase (AST), alanine aminotransferase (ALT), and gamma glutamyl transferase (GGT), after adjusting for potential confounders (P < 0.05). The odds ratios of having abnormal ALT levels were statistically significant in the highest mercury quartile compared to those with the lowest quartile. Particularly, regular alcohol drinkers showed greater effect estimates of mercury on the liver function than non-drinkers groups. There was no mediation effect of oxidative stress in the relationship between blood mercury concentrations and liver function.

CONCLUSIONS

Our results suggest that blood mercury levels are associated with elevated liver enzymes and interact with alcohol consumption for the association in the elderly.

Pre-treatment estimation of future remnant liver function using gadoxetic acid MRI in patients with HCC

BACKGROUND & AIMS

This study aimed to determine whether the predicted remnant liver function on dynamic hepatocyte-specific contrast media-enhanced magnetic resonance (DHCE-MR) imaging correlates with the results of the indocyanin green retention test (ICG R₁₅) after hepatic resection or radiofrequency ablation (RFA).

METHODS

This prospective multicenter study was approved by the Institutional Review Boards of each hospital. Informed consents were obtained from all. DHCE-MRI and ICG R₁₅ were performed in 57 patients scheduled to undergo hepatectomy or RFA for hepatocellular carcinoma, once before treatment and repeated on post-treatment day 3. In nine donors and three recipients, DHCE-MRI and ICG R₁₅ were performed only preoperatively. The predicted remnant liver function (HEFml) was estimated using the hepatic extraction fraction (HEF) multiplied by the remnant liver volume, and compared with post-treatment ICG R₁₅. Intra-individual heterogeneity of HEF was assessed using pooled coefficients of variation (CV) among hepatic segments. Finally, development of post-treatment hepatic failure was assessed according to the 50-50 criteria on post-treatment day 5.

RESULTS

Predicted remnant HEFml showed a negative correlation with post-treatment ICG R₁₅ (r=-0.45, p=0.001), whereas liver volume did not (p>0.05). There were significant correlations between pre-treatment HEFml and pre-treatment ICG R₁₅ (r=-0.33, p=0.006) and between post-treatment HEFml and post-treatment ICG R₁₅ (r=-0.54, p<0.001). Pooled CV among segmental HEFs was 12.6%. No patients showed post-treatment liver failure on post-treatment day 5.

CONCLUSIONS

DHCE-MRI using Gd-EOB-DTPA was able to provide both global and segmental liver function information, and post-treatment remnant liver function predicted on pre-treatment DHCE-MRI showed a significant negative correlation with post-treatment ICG R₁₅.

LAY SUMMARY

Post-treatment liver function could be predicted at pre-treatment DHCE-MRI. Liver function was heterogeneous among the liver segments. Liver anatomy, disease extent, and underlying liver function can be assessed in one DHCE-MRI examination.

CLINICAL TRIAL NUMBER

ClinicalTrials.gov number, NCT01490203.

Estimation of Upper Limit of Normal for Serum Alanine Transaminase in Healthy South Indian Population

Alanine aminotransferase (ALT) is the most common and cost effective screening test for asymptomatic liver disease. There is paucity of data on normal ALT among healthy individuals in India. An observational cross sectional study was conducted from January to July 2013 to estimate the upper limit of normal for ALT in healthy south Indian population. Adults undergoing voluntary or pre-employment health screening were included. Those with current and past alcoholism or smoking, acute illness or hospitalization during preceding 12 months, non-steroidal anti-inflammatory or over the counter medication use within a month, current or past intake of herbal medications, any chronic medical illness, abnormal body mass index (BMI), fatty liver in ultrasound, abnormality in haemoglobin, platelet count, blood sugar, creatinine, lipid profile and thyroid function test and positive serology (Hepatitis B, C or HIV) were excluded. A total of 2600 subjects were screened. 344 were included for analysis. Mean age was 35 years in men and 34.83 years in women, with a mean BMI of 22.2 kg/m² in men and 21.8 kg/m² in women. The mean ALT in men and women were 21.87 ± 2.9 (97.5th percentile 28 U/L) and 19.35 ± 3.3 (97.5th percentile 24 U/L) respectively. In conclusion, mean and upper limit of ALT (97.5th percentile) in south Indian men was 21.87 and 28 IU/L and women were 19.35 and 24 IU/L respectively. There is a need to re-consider ALT levels in our population for better detection of individuals at risk for liver disease.

Biochemical Profile of Nonalcoholic Fatty Liver Disease Patients in Eastern India with Histopathological Correlation

Aminotransferase assay is often used as a screening test as well as an endpoint for resolution of disease in nonalcoholic fatty liver disease (NAFLD). Aim of the study was to evaluate the relationship of transaminase level with metabolic variables and histology in NAFLD. Single center observational study was conducted in a gastroenterology clinic at Cuttack in coastal Odisha. Subjects were consecutive patients presenting with functional bowel disease and undergoing abdominal sonography. All participants were evaluated for the presence of metabolic syndrome (MS), insulin resistance, liver function test and lipid profile. Various parameters were compared between NAFLD subjects and controls. 53.5 % of NAFLD had normal serum transaminases, whereas 20.8 % of healthy controls had transaminitis. NAFLD patients had significantly higher BMI, fasting plasma glucose, serum transaminases, serum triglycerides, serum insulin and homeostatic model assessment (HOMA) IR than controls. NAFLD patients who had transaminitis had significantly higher incidence of MS and higher mean HOMA IR than those without. There was no significant difference in histopathological features between NAFLD with and without transaminitis. To conclude, over half of NAFLD subjects do not have transaminitis while transaminitis is present in a fifth of healthy people without fatty liver. Hence serum transaminase should not be used as screening test for NAFLD. NAFLD patients with transaminitis had a higher incidence of MS and insulin resistance than those without. However, there was no significant difference in histopathological features between these two groups.

Association of hypertriglyceridemic-waist phenotype with liver enzymes and cardiometabolic risk factors in adolescents: the CASPIAN-III study

OBJECTIVE

This study aims to investigate the role of metabolic syndrome (MetS) and the hypertriglyceridemic-waist (HW) phenotype in determining cardiometabolic risk factors and elevated liver enzymes in a national sample of Iranian pediatric population.

METHOD

This nationwide study was conducted in the framework of the third survey of a surveillance program. Students, aged 10-18 years, were recruited from 27 provinces in Iran. The prevalence of cardiometabolic risk factors was compared in students with and without HW and MetS. The association of HW with different cardiometabolic risk factors was determined.

RESULTS

The mean age of studied population was 14.73±2.41 years. Prevalence of HW and MetS was 3.3% and 4%, respectively. Sixty-nine (71.1%) participants with HW had MetS. The prevalence of obesity, elevated systolic blood pressure, hypercholesterolemia, and elevated alanine aminotransaminase (ALT) was significantly higher in subjects with HW phenotype and MetS than in their peers (p<0.05). A significant association was observed between HW and elevated levels of cholesterol and ALT, as well as between obesity and low HDL-C (p<0.05).

CONCLUSIONS

The current findings serve as complementary evidence to previous studies, which have been mainly conducted among adults, suggesting that the HW phenotype is associated with cardiometabolic risk factors, especially with elevated cholesterol and ALT. The authors propose that, in primary care settings and in large epidemiological studies, the measurement of all MetS components can be replaced by studying HW as a screening tool for identifying children at high risk for cardiometabolic disorders.

Prospective association of liver function biomarkers with development of hepatobiliary cancers

INTRODUCTION

Serum liver biomarkers (gamma-glutamyl transferase, GGT; alanine aminotransferase, ALT; aspartate aminotransferase, AST; alkaline phosphatase, ALP; total bilirubin) are used as indicators of liver disease, but there is currently little data on their prospective association with risk of hepatobiliary cancers.

METHODS

A nested-case control study was conducted within the prospective EPIC cohort (>520,000 participants, 10 European countries). After a mean 7.5 mean years of follow-up, 121 hepatocellular carcinoma (HCC), 34 intrahepatic bile duct (IHBC) and 131 gallbladder and biliary tract (GBTC) cases were identified and matched to 2 controls each. Circulating biomarkers were measured in serum taken at recruitment into the cohort, prior to cancer diagnosis. Multivariable adjusted conditional logistic regression was used to calculate odds ratios and 95% confidence intervals (OR; 95%CI).

RESULTS

In multivariable models, 1SD increase of each log-transformed biomarker was positively associated with HCC risk (OR(GGT)=4.23, 95%CI:2.72-6.59; OR(ALP)=3.43, 95%CI:2.31-5.10;OR(AST)=3.00, 95%CI:2.04-4.42; OR(ALT)=2.69, 95%CI:1.89-3.84; OR(Bilirubin)=2.25, 95%CI:1.58-3.20). Each liver enzyme (OR(GGT)=4.98; 95%CI:1.75-14.17; OR(AST)=3.10, 95%CI:1.04-9.30; OR(ALT)=2.86, 95%CI:1.26-6.48, OR(ALP)=2.31, 95%CI:1.10-4.86) but not bilirubin (OR(Bilirubin)=1.46,95%CI:0.85-2.51) showed a significant association with IHBC. Only ALP was significantly associated with GBTC risk (OR(ALP)=1.59, 95%CI:1.20-2.09).

CONCLUSION

This study shows positive associations between circulating liver biomarkers in sera collected prior to cancer diagnoses and the risks of developing HCC or IHBC, but not GBTC.

Incidence of antituberculosis-drug-induced hepatotoxicity and associated risk factors among tuberculosis patients in Dawro Zone, South Ethiopia: A cohort study

BACKGROUND

Antituberculosis drugs cause hepatotoxicity in some individuals leading to acute liver failure, which results in death. Such phenomena limit the clinical use of drugs, contributing to treatment failure that possibly causes drug resistance. Furthermore, associated risk factors for the development of antituberculosis-drug-induced hepatotoxicity (anti-TB-DIH) are found to be controversial among different study findings.

METHODS

A prospective cohort study was conducted from May 2014 to October 2014 in Dawro Zone, Tercha District Hospital Laboratory, South Ethiopia. One hundred and twenty-four new tuberculosis-positive individuals available from Tercha Hospital and five health centers during data collection were consecutively included. The sociodemographic data and anthropometric measurement were obtained. Then, 5mL of venous blood was drawn from each individual, and the alanine transaminase, aspartate transaminase, and total bilirubin were measured photometrically at baseline, and then continuously monitored by measuring these liver enzymes every 2weeks for 2months. Data were analyzed with SPSS version 20 for Windows (SPSS Inc., Chicago, IL, USA).

RESULTS

The incidence of anti-TB-DIH was found to be 8% (10 patients out of 124). Raised serum transaminase and bilirubin level, as well as signs and symptoms of hepatotoxicity (nausea, anorexia, vomiting, malaise, and jaundice), were observed in the cases. The onset of hepatotoxicity ranged from 13days to 58days (median, 26days) after treatment was initiated. Of the various risk factors analyzed, only high alcohol intake was associated with the incidence of anti-TB-DIH (odds ratio=9.3, 95% confidence interval 1.8-47, p<.007). Age, gender, extent of tuberculosis disease, and malnutrition were not significantly associated with anti-TB-DIH.

CONCLUSION

The incidence of anti-TB-DIH in Dawro Zone was high. The drug responsible for the hepatotoxicity was not known. However, chronic high alcohol intake was associated with the development of anti-TB-DIH.

Routine Monitoring of Liver, Renal, and Hematologic Tests After Single- or Double-Dose Methotrexate Treatment for Ectopic Pregnancies After In Vitro Fertilization

STUDY OBJECTIVE

To investigate the trends in liver function tests (LFTs), renal function tests (RFTs), and complete blood count (CBC) between day 1 and day 7 after single- or double-dose methotrexate (MTX) treatment for sonographically confirmed ectopic pregnancies.

DESIGN

Single center, retrospective chart review (Canadian Task Force classification II-3).

SETTING

University-affiliated center.

PATIENTS

All patients with a sonographically confirmed ectopic pregnancy after fresh in vitro fertilization-embryo transfer cycles between January 2004 and June 2013 treated with MTX were included.

INTERVENTIONS

Single- or double-dose MTX treatment.

MEASUREMENTS AND MAIN RESULTS

LFTs, specifically alanine aminotransferase (ALT), aspartate aminotransferase (AST), albumin, and total bilirubin levels, were measured on day of MTX administration (baseline) and 7 days later (day 7). Similar measurements of RFTs (blood urea nitrogen [BUN] and creatinine) and CBC (white blood cell [WBC] and platelets) were also performed. The change in LFTs, RFTs, and CBC (Δ) between baseline and day 7 was calculated for both single- and double-dose MTX protocols. Furthermore, the change in LFTs, RFTs, and CBC (Δ baseline vs day 7) for single- and double-dose MTX protocols were compared. Complete data was available for 107 patients: 89 (83.2%) and 18 (16.8%) patients received single- and double-dose MTX treatment, respectively. For either single- or double-dose treatment, no significant difference was found between baseline and day 7 ALT, AST, albumin, total bilirubin, BUN, creatinine, WBC, or platelet levels after MTX treatment. A comparison of post-treatment changes in LFTs, RFTs, and CBC (Δ baseline vs day 7) also showed no difference between single- and double-dose protocols.

CONCLUSION

Our study suggests that repeating LFTs, RFTs, or CBC on day 7 after single- or double-dose MTX treatment for sonographically confirmed ectopic pregnancies may not be necessary in patients with normal baseline testing on day 1.

Review and Recommendations for the Component Tests in the Liver Function Test Profile

Pathology laboratories group some tests that they perform on their high throughput biochemistry analysers into profiles of tests that are associated with different organs (e.g. liver function tests-LFT). The components of these profiles are historic and often vary between different laboratories. This can lead to confusion and begs the question of what should be in a particular profile. In community medicine profiles may be used as screening tests but some of the components of the profiles may have low sensitivity and specificity and may produce both false positives and negatives. The LFT may include components which are poor liver function tests but are sensitive to fatty liver and hence elevations may cause unnecessary concern. Harmonisation of clinical chemistry reference intervals and units is occurring now so it is time to consider a similar process for components of a profile. A proposed list of analytes to be performed in the LFT profile is given.