Prevalence and severity of liver enzyme alterations in COVID-19 and association with patient-centered outcomes

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By Tarun Sai LomteNov 15 2022Reviewed by Danielle Ellis, B.Sc.

In a recent study posted to medRxiv*, researchers examined the prevalence of changes in liver enzymes in coronavirus disease 2019 (COVID-19).

Study: Liver injury in hospitalized patients with COVID-19: An International observational cohort study. Image Credit: Magic mine/Shutterstock

*Important notice: medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.

Background

The COVID-19 pandemic remains a substantial contributor to global morbidity and mortality. Although respiratory manifestations are predominant in COVID-19, increasing evidence indicates the involvement of multiple organs. Liver injury has been observed in 15% to 65% of COVID-19 patients. Abnormalities in liver enzyme levels have been associated with COVID-19 severity and higher mortality risk. 

The International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC), in collaboration with the World Health Organization, initiated the clinical characterization protocol and case report forms in January 2020 to collect information on demographics, disease severity, therapeutic strategies, and outcomes for patients hospitalized with COVID-19.

About the study

The present study evaluated the prevalence and severity of liver enzyme changes in patients hospitalized with COVID-19 using the ISARIC dataset. All hospitalized patients from January 30, 2021, to September 21, 2021, with suspected/confirmed infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were included in the primary analysis. Patients lacking data on clinical outcomes or liver enzyme tests were excluded.

Serum bilirubin, alanine aminotransferase (ALT), and aspartate aminotransferase (AST) measured at the time of or within 24 hours of hospitalization were considered for analysis. The normal upper limits were 1 mg/dL for serum bilirubin and 40 U/L for ALT and AST. A liver injury classification (LIC) score was assigned to patients at baseline – stages 0, I, and II for the normal (liver enzyme) state, liver injury, and severe liver injury, respectively.

The study’s primary exposure and outcome were baseline liver enzyme levels and in-hospital death, respectively. Secondary outcomes were admission to the intensive care unit (ICU), the requirement of oxygen therapy, ventilation, renal replacement therapy, and inotropes/vasopressors, and the hospital/ICU length of stay (LoS).

In addition, the researchers evaluated the associations between baseline liver enzymes and complications developed in the hospital. Logistic regression was used to determine the relationship between exposure and outcome variables. Sensitivity analysis was performed by including patients with laboratory-confirmed SARS-CoV-2 infection. 

Results

The study included 17,531 patients from the ISARIC database based on eligibility. Most patients (60%) were male, and the average age was 56.5 years. Diabetes and hypertension were the common comorbidities. Chronic liver disease was observed in 3% of patients. Cough and fever were the common COVID-19 symptoms.

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Normal liver enzyme levels (LIC – stage 0) were recorded in 45.6% of patients, stage I liver injury was noted in 46.2% of patients, and stage II liver injury was identified in 8.2% of the cohort. Around 19% of stage 0 patients were admitted to the ICU, compared to 35% of stage I and 40. 1% of stage II patients.

Oxygen supplementation was required for 48%, 70.3%, and 75.9% of stage 0, I, and II patients, respectively. Invasive ventilation was required by 9.8% of stage 0 patients, 21.3% of stage I patients, and 27% of stage II patients. The median LoS in the hospital was nine days for stage 0 and II patients and eight days for stage I patients.

The median LoS in the ICU was seven, eight, and nine days for stage 0, I, and II patients, respectively. The crude mortality risk was 14.3% for patients with normal liver enzymes compared to 32.7% for those with stage II liver injury. Multivariable analyses revealed that liver injury stages I and II were associated with an increased risk of ICU admission, invasive ventilation, and death.

Furthermore, liver injury (stage I or II) was associated with increased odds of developing acute kidney injury (AKI), sepsis, and acute respiratory distress syndrome (ARDS). Moreover, stage II liver injury was associated with increased odds of developing neurologic and hemodynamic complications.

Conclusions

The study noted that liver enzyme abnormalities were common in COVID-19 patients at hospital admission. Increased severity of liver injury was associated with an elevated risk of ICU admission, invasive ventilation, and mortality. Adding evidence from an extensive dataset, these findings are largely concordant with previous studies. Taken together, the results suggest that COVID-19 patients commonly exhibit abnormal liver enzyme levels that are associated with poor clinical outcomes.

*Important notice: medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.

Journal reference:

• Preliminary scientific report.
  Tirupakuzhi Vijayaraghavan, B. et al. (2022) “Liver injury in hospitalized patients with COVID-19: An International observational cohort study”. medRxiv. doi: 10.1101/2022.11.06.22282006. https://www.medrxiv.org/content/10.1101/2022.11.06.22282006v1

Posted in: Medical Science News | Medical Research News | Disease/Infection News

Tags: Acute Kidney Injury, Acute Respiratory Distress Syndrome, Alanine, Chronic, Coronavirus, Coronavirus Disease COVID-19, Cough, covid-19, Diabetes, Enzyme, Fever, Hospital, Intensive Care, Kidney, Laboratory, Liver, Liver Disease, Mortality, Oxygen, Oxygen Therapy, Pandemic, Renal Replacement Therapy, Respiratory, SARS, SARS-CoV-2, Sepsis, Severe Acute Respiratory, Severe Acute Respiratory Syndrome, Syndrome

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Liver Enzyme Tests Often Fail to Identify Cirrhosis

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A majority of people with alcohol-related liver cirrhosis may have normal ALT levels.

January 19, 2022
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Standard liver enzyme tests that measure alanine aminotransferase (ALT) and aspartate transaminase (AST) can fail to detect alcohol-related liver cirrhosis, according to study results published in the American Journal of the Medical Sciences.

“The core message here is that if you just look at the test, you’ll miss the diagnosis,” Don Rockey, MD, of the Medical University of South Carolina, said in a press release. 

Heavy alcohol consumption can lead to serious liver disease, including advanced fibrosis, cirrhosis, liver cancer and the need for a liver transplant. Although cirrhosis is generally not reversible, early diagnosis offers an opportunity to reduce drinking and receive treatment that can reduce symptoms and increase life expectancy. 

Liver disease is often diagnosed with the help of liver enzyme tests. Elevated ALT and AST levels can indicate liver inflammation or injury. People with liver disease may also have elevated bilirubin levels, which can lead to jaundice.

Rockey and colleagues conducted a retrospective analysis to assess whether liver enzyme levels were normal or abnormal in people with alcohol-related cirrhosis. The study population included 78 people with the condition who were admitted to a medical center between January 2016 and December 2018. More than half were men, and the average age was 55 years.

Among this population, 70 people (90%) had normal ALT levels, 12 people (15%) had normal AST values and 20 people (26%) had normal bilirubin levels. All participants experienced decompensating events indicating liver failure, and one third died. The researchers found no association between liver complications or death and aminotransferase levels.

“Aminotransferase levels are often unremarkable in patients with alcohol-related cirrhosis and bear no relationship to clinical events or outcomes,” the researchers concluded. “Clinicians should be cautious when interpreting aminotransferases in patients with alcoholic cirrhosis.”

“We would see these patients with advanced disease and complications, yet their liver tests seemed to be normal,” Rockey said. “So if you just looked at their liver tests, you’d say, ‘Oh no problem,’ but in fact, that wasn’t the case.” 

These findings suggest that noninvasive methods, such as CT scans, MRI scans and elastography (FibroScan), may be more effective for early detection of liver cirrhosis.

Click here to read the study abstract.

Click here to learn more about alcohol-related liver disease.

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• #alcohol-related liver disease
• #cirrhosis
• #liver cancer
• #liver enzymes

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Tests for pancreatic necrosis

Pancreatic necrosis is a severe complication of acute pancreatitis in which cells die
pancreas. The pancreas (PZH) is a parenchymal organ, a gland of mixed secretion and
secretes enzymes into the lumen of the duodenum and hormones (insulin and glucagon) into the blood. When abused
alcoholic beverages, serious overeating and poisoning with certain chemicals, early
activation of enzymes produced by the pancreas, and a violation of their outflow, accompanied by an increase
pressure in the ducts, which leads to the destruction and digestion of the organ’s own cells.

This pathology requires stabilization of the patient’s condition with subsequent removal of necrotic tissues
glands surgically. Pancreatic necrosis is accompanied by a high probability of death.

What is pancreatic necrosis?

There are several main classifications of pancreatic necrosis. Depending on the extent of the process
pancreas isolated focal and diffuse forms.

Depending on the pathogenesis, hemorrhagic, fatty and mixed pancreatic necrosis is distinguished. With hemorrhagic
variant, the elastase enzyme destroys the walls of blood vessels, edema occurs and the nutrition of the organ is disrupted,
resulting in foci of necrosis. Fatty pancreatic necrosis occurs against the background of increased lipase activation,
destroying adipose tissue both inside the gland and around. Mixed necrosis is considered to be the most severe and
common.

In addition, the most important is the division of pancreatic necrosis into aseptic (sterile), without the presence of any
infectious agents, and infected, which is a more severe form in which
purulent-septic complications with higher mortality.

How is the pathological process in the pancreas clinically manifested?

The clinic develops rapidly, almost always associated with provoking factors – a lot of fatty foods, alcohol.
The most striking symptom is girdle pain, which radiates to the left hypochondrium and shoulder blade. pain almost
always accompanied by vomiting that does not bring relief. In addition, there are bloating, symptoms
dehydration – dry mouth, anuria (lack of urine), thirst, electrolyte imbalance. Maybe
discoloration of the skin to yellow with a bluish tint, fever.

With the progression of the process and the death of nerve endings, a decrease in the intensity of pain is possible
syndrome, which is a poor prognostic sign.

How is a pathology diagnosed? What tests are given for suspected pancreatic necrosis?

Since pancreatic necrosis is an acute surgical pathology, if the development of the process is suspected, the patient
urgently sent to the hospital. Diagnosis is primarily based on a thorough examination of the patient,
history taking and physical examination. In addition, a number of laboratory and instrumental
research.

1. Complete blood count

As with any other pathology, complete blood count is an important study in pancreatic necrosis. Appreciate
the number of basic formed elements that make up the blood, as well as hemoglobin and sedimentation rate
erythrocytes (ESR). With an inflammatory process in the pancreas or any other organ in the general analysis
ESR increases and leukocytosis is observed with a shift in the formula towards young forms (to the left). A sharp decline
red blood cells and hemoglobin can be observed with bleeding, which is accompanied by anemia. In some
cases, other pathological processes can be identified.

2. Blood chemistry (pancreatic enzymes)

The most important test for suspected acute pancreatitis and pancreatic necrosis is the blood chemistry.
First of all, pay attention to the amount of pancreatic enzymes in the blood. With pancreatic necrosis
there is a sharp increase in the level of lipase and amylase, which is associated with excessive destruction of cells and the release of
large amounts of enzymes in the blood. In addition, in the biochemical analysis in panreonecrosis, an increased
glucose levels, which may be associated with both initial functional pancreatic insufficiency and
impaired glucose tolerance, and with necrotic processes in the pancreas, due to which the production of
insulin.

Many other indicators are examined to assess the general condition of the patient and the impact of the process on other systems
biochemical reactions. For example, liver enzymes, creatinine and urea, cholesterol, lipoproteins of various
densities, protein fractions, etc. Be sure to evaluate electrolytes in the blood, as pancreatic necrosis
accompanied by dehydration and leads to various disorders.

3. Urinalysis for amylase

If possible, a urinalysis should be done if necrotizing pancreatitis is suspected. It is most important to assess the level
alpha-amylase (diastase) in biological fluid. When cells in the pancreas are destroyed,
an increase in the concentration of hydrolytic enzyme not only in the blood, but also in the urine. Normal amylase levels
in the urine should be in the range from 1 to 17 U / h (or about 9-430 U/l).

A urinalysis is also done to assess the function of the kidneys and other systems. Urine is examined macroscopically
(evaluate color, turbidity, odor), evaluate acidity (pH) and density, microscopically study the presence
proteins, blood cells, glucose, epithelial cells, etc.

Pancreatic necrosis cannot be diagnosed based on laboratory tests alone. Be sure to evaluate
clinical manifestations and apply methods of instrumental diagnostics – ultrasound examination of the abdominal organs
cavity, if necessary, CT, retrograde cholangiopancreatography (examination of the pancreatic ducts and bile ducts
by introducing contrast).

If you experience symptoms characteristic of a pathology of the pancreas, immediately consult a doctor for
diagnosis and treatment. Do not try to interpret the results of laboratory tests yourself. None
change is not a diagnosis.

Biochemical blood test in Moscow – hand over, price

A biochemical blood test provides invaluable information for various diseases, evaluating various parameters of metabolic processes (protein, fat, carbohydrate). The laboratory assistant determines a number of indicators that reflect the state of internal organs and systems, as well as the activity of certain enzymes contained in the blood serum. Biochemical indicators depend on the functioning of the cardiovascular, digestive, excretory, respiratory and endocrine systems, muscle and bone tissue, as well as the gastrointestinal tract.

Prices for biochemical blood tests

Test panels and examination algorithms

Indications for examination order

It is recommended to take a biochemical blood test:

It is recommended to donate blood biochemistry when the general condition worsens as a primary diagnosis.

Preparation for the procedure

To get the most reliable results, it is necessary to study a number of rules before taking blood for biochemical analysis (preparatory stage):

1. Avoid intense physical activity the day before the clinic visit associated with an increase in metabolites.

2. Avoid drinking alcoholic beverages.

3. Avoid stressful situations accompanied by an increase in adrenaline levels.

What can affect the result

Distortion of indicators is observed when taking certain medications. The results may be incorrect if fried, fatty foods and alcohol are consumed 1-2 before the study. Smoking should be avoided one hour before blood sampling.

Analysis

Indicators of a biochemical blood test that can be examined in the laboratory:

• proteins and their fractions;

• indicators of nitrogen metabolism;

• glucose and its metabolites;

• lipids;

• pigments;

• enzymes;

• markers of myocardial injury.

An increase or decrease in certain indicators indicates the development of a particular pathology. Laboratory studies are an important, but not definitive method for diagnosing diseases. It is possible to determine exactly what the patient is suffering from only on the basis of a comparison of objective data, the history of the development of the disease, laboratory and instrumental studies.

A blood test for biochemistry allows us to draw the following conclusions:

• assess the functional reserve of the liver and kidneys;

• determine if there is damage to cells, especially the heart muscle, which is important for the early diagnosis of myocardial infarction;

• identify any electrolyte disturbances that may affect the normal functioning of important organs;

• determine the likelihood of developing atherosclerosis and related complications;

• diagnose diseases associated with metabolic disorders.

Normal

Table – Indicators of a biochemical blood test

Explanation of indicators

A detailed biochemical blood test allows you to determine the following conditions:

• total protein. An increase indicates dehydration. This condition occurs with extensive burns (usually thermal), severe injuries and infections. A decrease in protein content is observed with an insufficient amount of protein foods in the diet. Its increased loss is characteristic of kidney diseases, diabetes mellitus, ascites, and oncopathology. Violation of protein synthesis is determined with liver damage, long-term treatment with corticosteroid hormones, as well as with a decrease in its absorption (enteritis, pancreatitis).

• Indicators of nitrogen metabolism. Proteins are broken down in the body to form the end product, urea. It is excreted by the kidneys, and an increase in its concentration in the blood indicates various pathologies of this organ (renal failure, glomerulonephritis, pyelonephritis, arterial hypertension, prostate adenoma). The reduced concentration of urea has no diagnostic value.

• Glucose and its metabolites. Examining the concentration of glucose in the blood is the most important step in diagnosing diabetes.

  In patients with diabetes, levels can be very high (hyperglycemia) or low (hypoglycemia). A critical change in glucose concentration can lead to coma and therefore requires immediate intensive care.

• Lipids. Triglycerides, cholesterol and its fractions are converted into lipids. The content of these substances increases with dyslipoproteinemia, which leads to the development of atherosclerosis.

• Bilirubin. In this group of indicators, the content of bile dyes is studied. An increase in serum levels indicates the presence of jaundice. Depending on the number of increases in concentration and on what type of pigment was increased (direct / indirect bilirubin), we can conclude the causes of jaundice: stopping the outflow of bile, destruction of liver cells; breakdown of erythrocytes.

• Enzymes. There are two large groups that are studied in the laboratory: non-specific (general metabolic processes) and specific (metabolism of certain tissues). These include aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH), alkaline phosphatase (ALP). Glutamate dehydrogenase increases with liver damage. Alpha-amylase and lipase increase in response to damage to the pancreas.

• Heart markers. They are delivered to the blood in large quantities when myocardial cells are damaged. An increase in concentration clearly indicates massive destruction of part of the heart muscle and allows you to accurately diagnose a heart attack.

Most often, a biochemical blood test after decoding does not allow an accurate diagnosis. However, knowledge of the causes of changes in the internal environment of the body directs the doctor to the right idea, which is the key to successful treatment.

Recommendations

For men, women and children, there are approximate limits of normal indicators of the studied parameters. Deviation from them indicates the development of dysfunction of internal organs or pathological processes in the body. A biochemical blood test allows not only to detect a health problem in a timely manner, but also to make a correct diagnosis, monitor the course of the disease and monitor the effectiveness of therapy.

Questions and answers

1. Do I need to cancel medications before a blood test for biochemistry?

   Significantly affect the results of biochemical tests drugs to lower blood pressure. Cancellation of drugs must be agreed with the doctor.

2. Where can I donate blood for biochemistry at an affordable price in Moscow?

   A general biochemical blood test at a low price can be taken at the RebenOK clinic. We employ experienced professionals and use modern equipment. How much does a biochemical blood test cost, check by phone or on the website of the medical center.

3. Are lab results reliable?

   The results of laboratory tests obtained at the RebenOK clinic meet international quality standards.

We promptly respond to additions and price changes in the price list. In order to avoid misunderstandings, it is recommended to clarify the full list of services and their cost at the clinic’s reception desk or by calling 8-495-104-35-35.
The price list posted on the site is not an offer. Medical services are provided on the basis of a concluded contract.

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A super doctor who saved a child from third otitis as a complication after an illness! Did all the research and analysis that was needed. She immediately prescribed treatment (and explained why it was not necessary to do what had been done before).