Background and Aims Severe Acute Respiratory Syndrome Coronavirus‐2 (SARS‐CoV‐2) associated acute liver injury (ALI) has been linked to poor outcomes in adults. Here we compare characteristics in children with elevated ALT (E‐ALT) in two distinct manifestations of the infection, multisystem inflammatory syndrome‐children (MIS‐C) and coronavirus disease 2019 (COVID‐19). Methods This is a retrospective study of patients ≤21 years of age with positive for SARS‐CoV‐2 PCR. E‐ALT was defined as alanine aminotransferase (ALT) > 40 U/L. Bivariate analysis and multivariable logistic regression were obtained to describe differences in children with and without E‐ALT in COVID‐19 and MIS‐C. Results E‐ALT was detected in 36% of the 291 patients; 31% with COVID‐19, and 51% with MIS‐C. E‐ALT in COVID‐19 was associated with obesity (P < .001), immunocompromised status (P = .04), and chronic liver disease (P = .01). In the regression models, E‐ALT in COVID‐19 was associated with higher c‐reactive protein (OR 1.08, P = .01) after adjusting for common independent predictors. Children with E‐ALT and MIS‐C were more often boys (P = .001), Hispanic (P = .04), or Black (P < .001). In MIS‐C, male gender (OR 5.3, P = .02) and Black race (OR 4.4, P = .04) were associated with increased odds of E‐ALT. Children with E‐ALT in both cohorts had significantly higher multiorgan dysfunction, longer hospitalization, and ICU stay. Children with MIS‐C had 2.3‐fold increased risk of E‐ALT compared to COVID‐19. No association was found between E‐ALT and mortality. Conclusion E‐ALT with SARS‐CoV‐2 presents as elevated transaminases without hepatic synthetic dysfunction. Patients with either manifestation of SARS‐CoV‐2 infection and E‐ALT experienced more severe disease.
Objective: The new GH receptor antagonist pegvisomant is the most effective medical therapy to normalize IGF-I levels in patients with acromegaly.
On the basis of strong research and consensus, nonalcoholic fatty liver disease (NAFLD) is the most common liver disease in children and is soon to be the most common indication for liver transplantation in adults. Although the disease begins as simple steatosis, some patients may progress to nonalcoholic steatohepatitis (NASH) and cirrhosis, making early identification and treatment critical.• The diagnosis of NAFLD can be challenging because patients are typically asymptomatic, with no major clinical symptoms of liver disease. Overweight and obese children are at the highest risk for disease. (1)(2)• On the basis of moderate research and consensus, serum ALT is usually mildly elevated but is an imperfect test with a low sensitivity for detecting NAFLD at commonly used thresholds.(10) Liver biopsy is still considered the gold standard for diagnosis but is too invasive for population-level screening and is often used selectively. Novel, noninvasive diagnostic modalities and serum biomarkers are currently being studied but warrant further validation, especially in children.• On the basis of moderate research and consensus, assessing serum liver tests in any overweight or obese child is reasonable.Liver disease should be suspected if the serum ALT is ‡22 U/L(0.37 mkat/L) in girls and ‡25 U/L (0.42 mkat/L) in boys. (10)Subspecialist referral should be considered for those with a normal BMI, persistent ALT elevation longer than 6 months,specific symptoms of advanced liver disease such as splenomegaly, or concerning laboratory findings on selected screening tests.• On the basis of strong research evidence, weight loss is the most efficacious treatment for NAFLD.• On the basis of some research and consensus, initiation of vitamin E therapy (400 IU BID) may be started, although its use probably should be restricted to those children with biopsy-proven disease. (12)• On the basis of some research and consensus, novel elastography-based imaging modalities are being studied in children and several drugs show promise in treating NAFLD.
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