Prevalence and Characteristics of Hypoxic Hepatitis in COVID-19 Patients in the Intensive Care Unit: A First Retrospective Study

Abstract

Purpose: Coronavirus disease 2019 (COVID-19) has been associated with acute liver injury in reports worldwide. But no studies to date have described hypoxic hepatitis (HH) in patients with COVID-19. We aim to identify the prevalence of and possible mechanisms of HH in COVID-19 patients in the Intensive Care Unit (ICU).Methods: This retrospective study was conducted on 51 patients with confirmed SARS-CoV-2 infection in the ICU at Zhongnan Hospital of Wuhan University from December 21, 2019, to March 11, 2020. Information on clinical features of enrolled patients was collected for analysis.Results: HH was observed in 5.88% of the ICU patients with SARS-CoV-2 infection. All HH patients were progressing to respiratory failure and peak alanine aminotransferase (ALT) values were 1665, 1414, and 1140 U/L during hospitalization, respectively. All patients with HH died as a result of the deterioration of multiple organ failure (MOF). The dynamic changes of ALT, aspartate transaminase (AST), and total bilirubin (TBIL) levels were more dramatic in HH groups. Levels of TBIL, C-reactive protein (CRP), procalcitonin (PCT), and interleukin-6(IL-6) showed statistically significant elevation in HH cases compared with that in non-HH cases (P < 0.001). Besides, the median survival time of the HH group was significantly shorter than the non-HH group (P < 0.05).Conclusions: In ICU, HH was not a rare condition in patients with severe COVID-19 and has a high mortality. The main causes of HH are respiratory and cardiac failure and may be associated with the immune-mediated inflammatory response. Clinicians should search for any underlying hemodynamic or respiratory instability even in patients with normal ALT levels on admission.

Acute hepatitis with portal and mesenteric vein thrombosis revealing SARS-CoV-2 infection: Case report and literature review

“…Ischemic hepatitis (hypoxic hepatitis) is one potential mechanism behind lessened perfusion of the liver, and discovers as ALT immediate and extreme elevation [ 12 , 13 ]. A study done by Dunn et al [ 14 ] has stated three possible mechanisms of this injury: hepatic ischemia, venous congestion, and arterial hypoxemia.…”

“…A study done by Dunn et al [ 14 ] has stated three possible mechanisms of this injury: hepatic ischemia, venous congestion, and arterial hypoxemia. The respiratory failure caused by SARS-COV2 can reduce oxygen feeding to the liver [ 13 , 14 ]. According to Kulkarni et al [ 15 ], the COVID-19 disease has impact on hepatic panel.…”

Liver Injury in Patients with Coronavirus Disease 2019 (COVID-19)—A Narrative Review

“…The pathogenesis of liver injury caused by SARS-CoV-2 is still unclear. Several possible mechanisms are taken under consideration: direct cytopathic effect of the virus through the ACE2 receptor, immune-mediated hepatitis as a result of uncontrolled inflammatory response following COVID-19 infection, leading to cytokine storm syndrome, anoxia as a cause of hypoxic hepatitis due to pneumonia and respiratory failure and drug-induced liver injury secondary to medications used for the treatment, among others, as well as antipyretic drugs or antiviral agents (Figure 1) [19,[28][29][30].…”

Liver dysfunction as a cytokine storm manifestation and prognostic factor for severe COVID-19

“…Levels of total bilirubin (TBIL), C-reactive protein (CRP), procalcitonin, and interleukin-6 (IL-6) show a statistically significant elevation in HLI cases compared with that in non-HLI cases. Besides, the median survival time of patients with HLI is significantly shorter than that of those not developing HLI[ 9 ].…”