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      Impact of SARS-CoV-2 Infection on Patients Suffering from Liver Injury

      * ,
      Digestive Diseases (Basel, Switzerland)
      S. Karger AG

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          Dear Editor, With great interest, we have read the recent article by Anastasioua et al. [1], wherein the authors described the effect of SARS-CoV-2 infection on mortality in patients suffering from Mild or severe liver injury. They demonstrated that while the mild liver injury was not associated with worse outcome in their cohort, cohart with severe liver injury showed multiple-organ failure and acute vascular events [1] leading to higher mortality. While the findings of study are intriguing, we have few concerns about the study design as well as few suggestions which would bring better insight to the study. 1. Acute liver failure is a rare condition in which massive liver injury is associated with the rapid development of hepatic encephalopathy increasing the mortality in this group of patients [2, 3]. In the present study, it is very difficult to conclude that the death rate is higher in group 3 due to the infection of SARS-CoV-2. 2. Present study would have been more impactful if authors included ALF patients without SARS-CoV-2 infection. 3. The severity due to SARS-CoV-2 infection in majority of cases is directly propostional to blood oxygen satutration levels (SpO2) [4]. However, the authors did not investigated it. This may have provided a better understanding of role of SARS-CoV-2 infection in the higher moratlity rate among the groups. 4. It is surprizing that authors did not discussed the aetiology of ALF patients such as viral hepatitis, Alcoholic hepatitis, Autoimmune hepatitis, Wilson disease, or sepsis etc. The mortality rate in ALF patients varies and dependent upon multiple factors such as aetiology, age, sex, and supportive care [5]. 5. Authors classified patient on the basis of ALT and bilirubin levels but there is significant variation of age among the groups and the consequence of this variation is not discussed. However, we agree with the authors that the fate of COVID-19 majorly depends on the comorbidity and age of the infected patients. Conflict of Interest Statement The authors have no conflicts of interest to declare. Funding Sources Department of Science and Technology, Govt. of India. Grant No. [DST/INSPIRE/04/2018/000019].

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          Most cited references5

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          Is Open Access

          Considerations for target oxygen saturation in COVID-19 patients: are we under-shooting?

          Background The current target oxygen saturation range for patients with COVID-19 recommended by the National Institutes of Health is 92–96%. Main body This article critically examines the evidence guiding current target oxygen saturation recommendation for COVID-19 patients, and raises important concerns in the extrapolation of data from the two studies stated to be guiding the recommendation. Next, it examines the influence of hypoxia on upregulation of ACE2 (target receptor for SARS-CoV-2 entry) expression, with supporting transcriptomic analysis of a publicly available gene expression profile dataset of human renal proximal tubular epithelial cells cultured in normoxic or hypoxic conditions. Finally, it discusses potential implications of specific clinical observations and considerations in COVID-19 patients on target oxygen saturation, such as diffuse systemic endothelitis and microthrombi playing an important pathogenic role in the wide range of systemic manifestations, exacerbation of hypoxic pulmonary vasoconstriction in the setting of pulmonary vascular endothelitis/microthrombi, the phenomenon of “silent hypoxemia” with some patients presenting to the hospital with severe hypoxemia disproportional to symptoms, and overburdened health systems and public health resources in many parts of the world with adverse implications on outpatient monitoring and early institution of oxygen supplementation. Conclusions The above factors and analyses, put together, call for an urgent exploration and re-evaluation of target oxygen saturation in COVID-19 patients, both in the inpatient and outpatient settings. Until data from such trials become available, where possible, it may be prudent to target an oxygen saturation at least at the upper end of the recommended 92–96% range in COVID-19 patients both in the inpatient and outpatient settings (in patients that are normoxemic at pre-COVID baseline). Home pulse oximetry, tele-monitoring, and earlier institution of oxygen supplementation for hypoxemic COVID-19 outpatients could be beneficial, where public health resources allow for their implementation.
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            Aetiology and outcome of acute liver failure.

            Acute liver failure (ALF) is a clinical syndrome characterized by the sudden onset of coagulopathy and encephalopathy. The outcome is unpredictable and is associated with high morbidity and mortality. We reviewed our experience to identify the aetiology and study the outcome of acute liver failure.
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              Acute liver failure and liver transplantation.

              Acute liver failure (ALF) is defined by the presence of coagulopathy (International Normalized Ratio ≥ 1.5) and hepatic encephalopathy due to severe liver damage in patients without pre-existing liver disease. Although the mortality due to ALF without liver transplantation is over 80%, the survival rates of patients have considerably improved with the advent of liver transplantation, up to 60% to 90% in the last two decades. Recent large studies in Western countries reported 1, 5, and 10-year patient survival rates after liver transplantation for ALF of approximately 80%, 70%, and 65%, respectively. Living donor liver transplantation (LDLT), which has mainly evolved in Asian countries where organ availability from deceased donors is extremely scarce, has also improved the survival rate of ALF patients in these regions. According to recent reports, the overall survival rate of adult ALF patients who underwent LDLT ranges from 60% to 90%. Although there is still controversy regarding the graft type, optimal graft volume, and ethical issues, LDLT has become an established treatment option for ALF in areas where the use of deceased donor organs is severely restricted.

                Author and article information

                Dig Dis
                Dig Dis
                Digestive Diseases (Basel, Switzerland)
                S. Karger AG (Allschwilerstrasse 10, P.O. Box · Postfach · Case postale, CH–4009, Basel, Switzerland · Schweiz · Suisse, Phone: +41 61 306 11 11, Fax: +41 61 306 12 34, karger@karger.com )
                9 October 2020
                : 39
                : 1
                : 1-2
                Department of Microbiology, All India Institute of Medical Sciences, Bhopal, India
                Author notes
                *Ashish Kumar Vyas, Department of Microbiology, All India Institute of Medical Sciences Bhopal, Saket Nagar, Bhopal 462024 (India), a88_ashish@ 123456yahoo.co.in
                Copyright © 2020 by S. Karger AG, Basel

                This article is made available via the PMC Open Access Subset for unrestricted re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the COVID-19 pandemic or until permissions are revoked in writing. Upon expiration of these permissions, PMC is granted a perpetual license to make this article available via PMC and Europe PMC, consistent with existing copyright protections.

                : 15 September 2020
                : 2 October 2020
                : 2021
                Page count
                References: 5, Pages: 2
                Liver: Letter to the Editor


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