Yoğun Bakımda COVID-19 ve Karaciğer Yetmezliği
Özet
Covid-19 enfeksiyonu, hastaların %14,8 ila %53'ünde karaciğer hasarına neden olan çok faktörlü bir halk sağlığı problemidir. Bu hasar, özellikle yoğun bakımdaki hastalarda aminotransferaz (AST ve ALT) yüksekliği ile kendini gösterir. Hasarın temel nedenleri arasında immünolojik yanıt (sitokin fırtınası), doğrudan viral hasar, hipoksi, hipotansiyon ve başta favipiravir ile parasetamol olmak üzere tedavi süreçlerinde kullanılan hepatotoksik ilaçlar yer almaktadır. Kronik karaciğer yetmezliği ve alkole bağlı karaciğer hastalığı (ArLD) olan bireyler ile ileri yaştaki hastalar en yüksek risk grubundadır. Karaciğer nakli olan hastaların ise mortalite oranlarında genel popülasyona göre belirgin bir artış gözlenmemiştir. Tedavi yaklaşımında öncelik; yatak başı ultrasonografi takibi, hemodinamik stabilizasyonun sağlanması, potansiyel hepatotoksik ajanlardan kaçınılması ve karaciğer koruyucu anti-inflamatuar ilaçların (polien fosfatidil kolin, glisirizik asit vb.) entegre edilmesidir.
Covid-19 infection causes multi-factorial liver damage in 14.8% to 53% of hospitalized patients, characterized primarily by elevated aminotransferases (AST and ALT) in intensive care units. The primary pathogenic mechanisms driving this hepatic injury include immunologic damage from cytokine storms, direct viral entry via ACE-2 receptors on cholangiocytes and hepatocytes, systemic hypoxia, hypotension, and drug-induced liver injury from antivirals like favipiravir or high-dose acetaminophen. Older age, advanced stage liver disease, and alcohol-related liver disease represent major risk factors for poor prognosis, whereas liver transplant recipients show no significant increase in mortality. Management strategies in critical care focus on continuous liver function monitoring, bedside ultrasound evaluation, maintaining hemodynamic stability, avoiding hepatotoxic drugs, and utilizing hepatoprotective, anti-inflammatory agents to support recovery.
Referanslar
Zhang C, Shi L, Wang FS. Liver injury in COVID-19: management and challenges. Lancet Gastroenterol Hepatol 2020; 5: 428-430 DOI: 10.1016/S2468-1253(20)30057-1
Spearman CW, Aghemo A, Valenti L. COVID-19 and the liver: a 2021 update. Liver International 41(9), 1988-1998.
Kulkarni, AV., Kumar P., Tevethia, HV., et al. Systematic review with meta‐analysis: liver manifestations and outcomes in COVID‐19. Alimentary pharmacology & therapeutics, 52(4), 584-599.
K Luo, Y Chen, J Yang, et al. – Liver Injury and Elevated Levels of Interleukin-2 Receptor, and Interleukin-6 Predict the Severity in Patients With COVID-19. Frontiers in Public Health, 2021
Gomez-Mesa JE, Galindo-Coral S, Montes MC. Thrombosis and coagulopathy in COVID-19. Current problems in cardiology, 46(3), 100742.
Sonzogni A, Previtali G, Seghezzi M et al. Liver histopathology in severe COVID 19 respiratory failure is suggestive of vascular alterations. Liver International 2020, 40.9: 2110-2116. 2020.
Li, D., Ding, X., Xie, M., et al. COVID-19-associated liver injury: from bedside to bench. Journal of Gastroenterology, 56(3), 218-230.
Lagana, S., Kudose, S., Iuga, A. C., et al. Hepatic pathology in patients dying of COVID-19: a series of 40 cases including clinical, histologic, and virologic data. Modern Pathology, 33(11), 2147-2155.
Guan, W. J., Ni, Z. Y., Hu et al. Clinical characteristics of coronavirus disease 2019 in China. New England journal of medicine, 382(18), 1708-1720.
Chai X, Hu L, Zhang Y. Specific ACE2 expression in cholangiocytes may cause liver damage after 2019-nCoV infection. bioRxiv. 2020. doi: 10.1101/2020.02.03.931766
Nardo AD, Schneeweiss-Gleixner M, Bakail M, et al. Pathophysiological mechanisms of liver injury in COVID-19. Liver International. 2021;41:20–32.
S Jonsdottir, MB Arnardottir, JA Andresson , Prevalence, clinical characteristics and outcomes of hypoxic hepatitis in critically ill patients, Scandinavian Journal of Gastroenterology 2021, doi/full/10.1080/00365521.2021.2005136
Liverpool Drug Interactions Group, Interactions with Experimental COVID-19 Therapies, 20.03.2020
GX Ortiz, G Lenhart, MW Becker, Drug-induced liver injury and COVID-19: A review for clinical practice World Journal of Hepatology
Muhović D, Bojović J, Bulatović A, et al. First case of drug-induced liver injury associated with the use of tocilizumab in a patient with COVID-19. Liver International. 2020;40:1901-1905
Olry, A. L Meunier, B Délire et al. Drug-induced liver injury and COVID-19 infection: the rules remain the same. Drug Safety. 43, 615–617 (2020)
Nesseler, N., Launey, Y., Aninat, C. et al (2012). Clinical review: the liver in sepsis. Critical care, 16(5), 1-8.
Barazzoni R, Bischoff SC, Krznaric Z ESPEN of expert statements and practical guidance for nutritional management individuals with SARS-CoV-2 infection. Clinical Nutrition. DOI:10. 1016/j.clnu.2020.03.022
Marjot, T., Moon, A. M., Cook, J. A., et al. Outcomes following SARS-CoV-2 infection in patients with chronic liver disease: an international registry study. Journal of hepatology, 74(3), 567-577.
Wu, J., Song, S., Cao, H. C, et al. Liver diseases in COVID-19: Etiology, treatment and prognosis. World journal of gastroenterology, 26(1
