key: cord-0904618-rgiwaqyc authors: Saithanyamurthi, Hemamala V.; Munirathinam, Manoj; Ananthavadivelu, Murali title: Prevalence of liver injury in 445 patients with Corona Virus Disease-19-Single-centre experience from southern India date: 2021-05-15 journal: Indian J Gastroenterol DOI: 10.1007/s12664-021-01147-x sha: 8fe3c687d8b289a2c999a46ba572a0f28612f7ec doc_id: 904618 cord_uid: rgiwaqyc BACKGROUND: Abnormal liver function tests (LFT) are common in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and vary from 15% to 53%. There are scanty data from India on the prevalence of liver injury in corona virus disease 2019 (COVID-19) patients. METHODS: We did this retrospective study in a tertiary care hospital, Chennai, India. Patients aged >18 years admitted with COVID-19 from May 1, 2020, to May 31, 2020, were included. We noted the demographic details, symptoms at presentation, history of pre-existing illnesses, and laboratory tests. We also recorded the patient’s clinical course and outcome. RESULTS: We took 445 patients for final analysis. Aspartate transaminase (AST) was borderline elevated in 47.5%, mildly elevated in 11.2%, moderately elevated in 2% and severely in 0.7%. Alanine transaminase (ALT) was borderline elevated in 28.7%, mildly elevated in 11.4%, and moderately elevated in 1.3%. Bilirubin and alkaline phosphatase were abnormal in only 19 (4.2%) and 15 (3.3%) patients, respectively. Patients with abnormal LFT were more likely to be symptomatic (90.3% vs. 80.6%, p 0.002). Respiratory symptoms (43.5% vs. 29.7%) and loose stools (11.4% vs. 3.4%) were also more common among them. Patients with abnormal LFT were more likely to have severe disease (25.2% vs. 13.6%, p value 0.003) and mortality (8.8% vs. 0.7%). CONCLUSION: Liver test abnormalities were widespread in patients with COVID-19. Most of the patients had borderline or mild transaminase elevation. Despite only mild changes, patients with abnormal LFT were more likely to be symptomatic and had more severe disease and mortality. Coronavirus, an enveloped single-stranded Ribonucleic acid (RNA) virus, is commonly seen in mammals and birds. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for the current corona virus disease 2019 (COVID-19) pandemic. As of 27/7/2020, there have been 16,096,741 confirmed cases of COVID-19, including 646,384 deaths, reported on WHO Dashboard. The clinical spectrum of COVID-19 ranges from mild asymptomatic cases to full-blown respiratory illness, acute respiratory distress syndrome (ARDS), or multi-organ dysfunction [1, 2] . The infection is particularly severe in patients with underlying comorbid conditions, such as diabetes, hypertension, and coronary artery disease. The typical clinical symptoms are fever, dry cough, and tiredness. In addition to that, breathlessness or chest pain are the serious complaints. In the previous severe acute respiratory syndrome outbreak in 2002, liver impairment was reported in up to 60% of patients [3] . Whereas, in the current COVID-19 pandemic, Zhang et al. reported hepatic dysfunction in 14% to 53% of the patients [3] . There is limited information describing the liver-related abnormalities in COVID-19 patients from India. This study presents the clinical data and analysis of 445 patients with COVID-19. They were admitted at a tertiary hospital in Chennai (India), in May 2020. Patients admitted and treated for COVID-19 in MIOT International Hospital, Chennai, between 1st and 31st May, 2020 were included in the study. Reverse transcriptase polymerase chain reaction (RT-PCR) for SARS-CoV-2 RNA from a nasopharyngeal and oropharyngeal swab confirmed COVID-19. The institutional ethical committee approved the study and exempted the patients' informed consent because of its retrospective nature. We collected the medical records of the patients from the hospital's information system. The information collected included demographic details, main symptoms at presentation, and any history of pre-existing illnesses like diabetes, hypertension, coronary artery disease, chronic obstructive pulmonary disease, chronic kidney disease and chronic liver disease. We also recorded the patients' clinical course, laboratory investigations, and outcome. Cut-off values for normal and abnormal LFT varies between various published studies. In this study, we have taken the cutoff values recommended by the American College of Gastroenterology (ACG) on the abnormal evaluation of liver tests [4] . As per the ACG guidelines, the upper limit of normal (ULN) for transaminases is considered 33 IU/L for males and 25 IU/L for females. Their guidelines define & borderline elevation as less than two times ULN & mild elevation as two to five times the ULN & moderate elevation as five to ten times the ULN & and severe elevation as levels more than ten times the ULN Additionally, any serum bilirubin and alkaline phosphatase values above the ULN was considered to be abnormal. Patients with abnormal LFT were considered to be Group 1, and those with normal LFT were considered to Group 2. Based on the 2019 American Thoracic Society guidelines on community-acquired pneumonia [5, 15] , patients with mild symptoms (i.e. fever, cough, expectoration, and other upper respiratory tract symptoms) were classified as The current Coronavirus pandemic has predominantly respiratory symptoms. Liver tests are abnormal in 15% to 53 % of the patients suffering from corona virus disease 2019 (COVID-19). Most of the patients have mild elevations in liver tests. It is the one of the initial study looking into the prevalence of liver abnormalities in Indian patients affected with COVID-19. More than half of the patients have transaminases above the normal limits Only a small number of patients have moderate to severe transaminase elevation based on the criteria defined by the American College of Gastroenterology. Patients with abnormal liver function tests are more likely to have severe disease and mortality. More research will be required to study whether the liver injury is due to the direct cytopathic effect of the virus or is due to the damage from systemic inflammation and cytokine storm. non-severe types. Patients with imaging feature suggestive of pneumonia and any of the following were classified as severe. i) Significantly increased respiration rate (RR): RR > 30 times/min; ii) Hypoxia: oxygen saturation (resting state) ALT and presence of severe disease with transaminase elevation suggest a possibility that in SARS-CoV-2 infection, more than the direct cytotoxic effects, liver injury from systemic cytokine storm can also play a major role causing transaminase elevation. Serum bilirubin and alkaline phosphatase were above the ULN in a very small number of patients. This was surprising, given that bile ductular cell is considered to be the primary site of attachment of SARS-CoV-2. This was noted in other studies too [9] . We also noticed that diabetes was more common in patients with abnormal LFT. Some of these patients can have underlying non-alcoholic steatohepatitis (NASH). Due to logistic restrictions during the pandemic, ultrasound abdomen was not done in our patients to rule out fatty liver. Patients with diabetes are known to have more severe disease and mortality [10] . Our study's main strength is the large number of patients. Main limitations of our study are non availability of ultrasound and not having taken the history of alcohol consumption. In conclusion, abnormal liver tests are common in patients with COVID-19. Most of the patients had borderline or mild transaminase elevation with normal bilirubin and alkaline phosphatase. Despite mild transaminase elevation, it is associated with more severe disease and mortality. An in depth prospective study to validate these findings and correlation with markers of disease severity are needed. 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The study was performed conforming to the Helsinki declaration of 1975, as revised in 2000 and 2008 concerning human and animal rights, and the authors followed the policy concerning informed consent as shown on Springer.com.Disclaimer The authors are solely responsible for the data and the contents of the paper. In no way, the Honorary Editor-in-Chief, Editorial Board Members, the Indian Society of Gastroenterology or the printer/ publishers are responsible for the results/findings and content of this article.