Liver function test abnormalities: Do they correlate with severity in dengue infection? An Indian perspective Ravilla S, Padmaprakash K V, Arun N, Kanth R,

ORIGINAL ARTICLE

Ahead of print publication

Liver function test abnormalities: Do they correlate with severity in dengue infection? An Indian perspective

Sreegeetha Ravilla¹, KV Padmaprakash², N Arun³, Ravi Kanth⁴
¹ Department of Medicine, Katuri Medical College, Guntur, Andhra Pradesh, India
² Department of Medicine, Base Hospital Delhi Cantt, New Delhi, India
³ Department of Medicine, Military Hospital, Jodhpur, Rajasthan, India
⁴ Department of Medicine, INHS Kalyani, Visakhapatnam, Andhra Pradesh, India

Date of Submission	24-May-2022
Date of Decision	19-Jun-2022
Date of Acceptance	20-Jun-2022
Date of Web Publication	09-Nov-2022

Correspondence Address:
Ravi Kanth,
INHS Kalyani, Visakhapatnam, Andhra Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmms.jmms_88_22

Abstract

Introduction: Involvement of the liver is frequently reported among patients with dengue infection, and liver enzymes are commonly deranged in dengue infection. Raised levels of alanine aminotransferase (ALT) in dengue infection were linked to worse outcomes. The present study was an attempt to study the liver function test abnormalities in dengue fever (DF) and its correlation with the severity of the disease. Methods: The present study was undertaken as a hospital-based retrospective study of DF patients in the age group of 15–60 years. Five hundred and thirty patients who met the eligibility criteria and were admitted to the study hospital during the duration of data collection period (July 2018 to July 2021), comprised the study sample. Differences in means were tested using ANOVA or Kruskal–Wallis test. The difference in proportions was tested using the Chi-square test. Results: Majority of the patients were males (73.4%) with a mean of 30.3 ± 9.7 years. A significant association was observed between clinical features of jaundice, hepatomegaly, splenomegaly, ascites, effusion, bleeding, organ failure, and severe forms of DF. There was a significant positive correlation between aspartate aminotransferase, ALT, and serum bilirubin values among patients with severe forms of DF. Conclusion: Significant proportions of patients with DF without warning signs and severe DF had deranged liver function parameters. A statistically significant association was observed between liver function parameters and the severity of dengue disease.

Keywords: Alanine aminotransferase, aspartate aminotransferase, dengue, liver function test, liver, severity

How to cite this URL:
Ravilla S, Padmaprakash K V, Arun N, Kanth R. Liver function test abnormalities: Do they correlate with severity in dengue infection? An Indian perspective. J Mar Med Soc [Epub ahead of print] [cited 2023 Mar 21]. Available from: https://www.marinemedicalsociety.in/preprintarticle.asp?id=360613

Introduction

Dengue, a mosquito-borne disease, is considered a major public health threat, worldwide. The disease is caused by the dengue virus (DENV, 1–4 serotypes), a virus of public health importance among other arboviruses in tropical and subtropical regions.^[1],[2] Over the past three decades, epidemics of dengue, have become a common and frequent issue, in India, especially in urban regions, which have now disseminated to rural zones and to the regions where it was not reported historically in the past.^[3] This suggests a change in geographical range and distribution of the disease, in addition to rising incidence and severity. The seroprevalence of dengue was reportedly high in the southern states (76·9%), followed by western (62·3%), and northern (60·3%) states.^[4] Management of dengue patients is mainly symptomatic, as there is no specific drug to treat the disease. Although most dengue infections are mildly symptomatic and self-limiting with symptomatic management, certain patients tend to develop severe complications, which require intensive medical care. These complications include but are not limited to, organ failure, which is seen in the late stage of the natural history of dengue. This provisions clinicians with a potential time window and opportunity to identify those patients who are at higher risk of developing grave complications.

In patients with severe dengue infections, there is capillary leakage, causing fluid accumulation in various body cavities apart from thrombocytopenia which is common in dengue fever (DF). DENV, serotype 2 in specific, blocks megakaryopoiesis and also leads to apoptosis of early megakaryocytic precursors, which eventually lead to thrombocytopenia.^[5] Yet another study postulated that DENV can lead to thrombocytopenia through platelet activation.^[6] Involvement of the liver is also frequently reported among patients with dengue, and liver enzymes are commonly deranged in dengue infections of all severity grades.^[7],[8],[9] Features of hepatitis are regularly reported in patients with DENV infection and the liver is the most commonly affected organ in fatal dengue cases.^[10] Raised levels of alanine aminotransferase (ALT) in dengue infection were noted to be linked to worse outcomes in various past research works.^[11] This derangement in liver functions could be attributed to the direct effect of DENV on hepatocytes or could be a consequence of host immune response dysregulation, to counteract infection.^[9] Transaminases are released into the blood from liver parenchyma, due to inflammation.^[12] Despite the established effects of DENV infection on the liver, research work on the subject is limited. The present study was an attempt to study the liver function test (LFT) abnormalities in DF and its correlation with the severity of the disease.

Materials and Methods

The present study was undertaken as a hospital-based retrospective study of dengue patients of either sex, in the age group of 15–60 years, who were diagnosed to have DF and admitted to the study hospital during the period July 2018 to October 2021, in Visakhapatnam, South-East India. Five hundred and thirty patients who met the eligibility criteria and were admitted to the study hospital during the duration of the study data collection period (July 2018 to July 2021) comprised the study sample. The institute's ethical committee approval was obtained for the study. DF was diagnosed in presence of the following three criteria: (i) positive test results for NS1 antigen or either DENV-specific immunoglobulin M antibody and (ii) absence of other etiology likely to explain the illness, if required. The severity of DF was graded into DF without warning signs (DFWS)/mild DF, dengue with warning signs, and severe DF (SDF) in compliance with the World Health Organization (WHO) criteria.^[13] Those with positive NS1 antigen tests were confirmed with dengue immunoglobulin by enzyme-linked immunoassay after 2 weeks. According to the WHO, probable dengue is defined as an acute febrile illness in a person that lived/traveled to a dengue-endemic area and has at least two features among the following: nausea and vomiting; rash; aches and pains; positive tourniquet test; and leukopenia. Warning signs include abdominal pain or tenderness, persistent vomiting, clinical fluid accumulation, mucosal bleed, lethargy or restlessness, liver enlargement >2 cm below the right costal margin, and increase in hematocrit (Hct) with a rapid decrease in platelet count. Further, severe dengue is defined in presence of evidence of either of the following three features: (i) severe plasma leakage leading to shock or fluid accumulation with respiratory distress, (ii) severe bleeding as judged by the clinician, and (iii) severe organ involvement such as liver (suggested by ALT or aspartate aminotransferase (AST) ≥1,000 IU/L), central nervous system (suggested by impaired consciousness), heart, or other organs. During the hospital stay, all patients diagnosed with DF were treated according to the WHO guidelines.^[13] According to the clinical requirement, patients were investigated to exclude other causes of acute febrile illnesses such as malaria, enteric fever, hepatitis A virus, etc., Serum levels of ALT and AST were chosen as a marker of liver injury. For a patient with multiple values of serum enzymes available during illness, ALT, AST, and alkaline phosphatase (ALP) value temporally closest to the nadir of platelets counts were included for analysis, and disease severity was also noted for the same day. To define the upper limit of normal (ULN), the cutoffs for ALT and AST were ascertained as 33 and 40 IU/L for men and 25 and 35 IU/L for women, respectively. A patient was assumed to sustain a liver injury at serum ALT >2 × ULN (ALT >66 IU/L for men, >50 IU/L for women).

Statistical analysis

Data entry was done in MS Excel 2019 and data analysis was carried out using IBM Statistical Package for the Social Sciences (SPSS) version 22.0, Armonk, NY, USA: IBM Corp. Categorical and continuous variables were presented as proportions and means with standard deviation (SD), respectively. Tests of normality were done to establish the parametric distribution of continuous variables. Differences in means between three groups were tested for statistical significance using ANOVA or Kruskal–Wallis test based on the parametric distribution of variables. Differences in proportions were tested using the Chi-square test. The correlation between two continuous variables was evaluated using Pearson correlation coefficient. A P < 0.05 was considered statistically significant.

Results

Of the 530 patients included in the study, the majority were males (73.4%) and were in the age ranging between 12 and 68 years with a mean of 30.3 ± 9.7 years. A significant association was observed between the presence of features such as giddiness, nausea, vomiting, rash, jaundice, hepatomegaly, splenomegaly, ascites, effusion, bleeding, shock, organ failure, and severe forms of DF [Table 1].

Table 1: Distribution of study participants based on dengue severity classification and clinical parameters

Click here to view

Hemoglobin and Hct were found to be significantly lower in SDF, whereas total leukocyte count was found to be significantly high in SDF. Almost 95.2% of the patients with SDF had a liver injury that was significantly high as compared to mild DF and DFWS (P < 0.001). Comparably, all liver function parameters (serum bilirubin, ALT, AST, AST/ALT, and ALP were grossly deranged in patients with SDF (P < 0.001). Furthermore, total protein and albumin levels were significantly less in patients with SDF (P < 0.001) [Table 2].

Table 2: Distribution of study participants based on dengue severity classification and laboratory investigation parameters

Click here to view

There was a significant positive correlation between AST, ALT, and serum bilirubin values among the patients with DF [Figure 1]. Furthermore, a significant negative correlation was observed between platelet counts and liver function parameters.

Figure 1: Correlation between liver function test parameters

Click here to view

On performing receiver operating characteristic curve analysis, the area under the curve (AUC) was found to be highest for AST (0.868) and ALT (0.852), followed by ALP (0.731) [Figure 2]. ALT levels above two times ULN showed 88.2% sensitivity and 60.7% sensitivity for SDF. ALT levels three times ULN showed 70.6% sensitivity and 76.4% specificity for SDF. AST levels above two times ULN showed 97.1% sensitivity and 56.8% sensitivity for SDF. AST levels three times ULN showed 79.4% sensitivity and 69.9% specificity for SDF.

Figure 2: ROC curve analysis for predicting the severity of dengue infection. ROC: Receiver operating characteristic

Click here to view

Discussion

The distribution of DENV infection in India is heterogeneous with higher incidences being reported from northern, western, and southern states, with increasing incidences of fatal infections every year, which necessitates the requirement of further research into potential factors that predict or determine the severity of the disease. There is heterogeneity in the distribution of various serotypes in different parts of the country and this leads to varying results from various studies carried out in different regions in India. The present study was carried out as an attempt to study the derangements in LFT parameters among patients with DF and its correlation with the severity of the disease. Inflammatory responses in dengue infection cause changes in hepatic parenchyma, leading to the release of aminotransferases into circulation.^[12] Further, abnormalities in LFT parameters are noted in patients with DF due to the direct effect of DENV on hepatocytes and Kupffer cells or due to the immune response of the host against DENV.^[14] These hypotheses substantiate the need for monitoring LFT parameters in patients with DF.^[15] Furthermore, in the past, abnormally elevated levels of aminotransferases and other LFT parameters, identical to those observed in hepatitis virus infections, have been documented in patients with DF.^[16]

Narasimhan et al.^[17] in their study reported that 82% had values of ALT above normal and 92% of patients had AST values above normal. Bilirubin levels were elevated in 5% of cases. ALP levels were elevated in 25% of cases; serum globulins were increased in 9% of cases. Serum proteins were low in 43% of cases and serum albumin was low in 31% of cases. Shastri et al.^[18] observed in their study that elevation of liver enzymes, especially ALT levels of more than 1000 IU/L was found in 35% of cases, the median value being 811 IU/L (range 74–3422) in nonsurvivors. Hepatic dysfunction in the form of raised bilirubin odds ratio of 7.002 (1.52–32.23) was associated with a significantly higher risk of mortality. Similar comparable increases in liver enzymes were noticed in the present study also but a rise in bilirubin levels was not significant between those with warning signs and those with severe infection. Shivkar et al.^[19] observed a negative correlation between platelet count with AST and ALT in all dengue patients irrespective of platelet count, between AST (r = −0.36) and ALT (r = −0.39) with that of platelet count (P < 0.001). An identical negative correlation was observed in the present study as well. A meta-analysis of 15 studies on liver enzyme abnormalities in patients with dengue found that 80% of dengue hemorrhagic fever (DHF) patients and 75% of DF patients had AST abnormalities, whereas 54% of DHF patients and 52% of DF patients had ALT abnormalities.^[20] This meta-analysis demonstrated the rise in AST was greater than that of ALT in dengue, which is the characteristic pattern of hepatic injury in dengue that differentiates dengue hepatitis from other causes of viral hepatitis. Concordant observations were documented in the present study with mean AST and ALT values of 179 U/L and 115U/L in patients with DFWS, whereas the mean values of AST and ALT were 265U/L and 191.5U/L in patients with SDF. Hypoproteinemia and hypoalbuminemia were reported in 16.5%–76% by various other studies.^{[14],[21],[22]} A similar trend of hypoproteinemia was seen among the participants of the present study as well. Md Sani et al.^[23] found AUC for AST and ALT as 0.78 and 0.69, respectively. Identical observations were derived in the present study with AUC for AST and ALT being 0.868 and 0.852. Priyangika et al.^[24] in their research work observed that AST and ALT did not have sufficient predictive power of severe dengue disease; however, it is important to note that the above study was conducted in Sri Lanka, where the epidemics could be due to different DENV serotypes. Irrespective of these facts, it is important that the treating physicians should be vigilant about the noticeably raised transaminase levels, for a potentially complicated disease course and necessitate close nursing of these patients for potentially severe diseases. One of the possible limitations of this study is that DENV serotyping could not be studied due to the feasibility and nonavailability of these facilities in the study hospital. As different regions have different serotypes, causing periodic epidemics, it is important that large-scale multicentric studies are carried out to establish the predictive role of LFT parameters in the severity of serotype-specific dengue disease.

Conclusion

The study reiterates the importance of performing simple LFTs at admission in dengue and predicting the severity of the disease. Ours is one of the largest studies with robust data in the Indian setting. Significant proportions of patients with DFWS and SDF had deranged liver function parameters. A statistically significant association was observed between LFT parameters and the severity of dengue infection. Large-scale multicentric prospective studies are required to establish this association among various DENV serotypes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Halstead SB. Dengue. Lancet 2007;370:1644-52.
2.	Mustafa MS, Rasotgi V, Jain S, Gupta V. Discovery of fifth serotype of dengue virus (DENV-5): A new public health dilemma in dengue control. Med J Armed Forces India 2015;71:67-70.
3.	Chakravarti A, Arora R, Luxemburger C. Fifty years of dengue in India. Trans R Soc Trop Med Hyg 2012;106:273-82.
4.	Murhekar MV, Kamaraj P, Kumar MS, Khan SA, Allam RR, Barde P, et al. Burden of dengue infection in India, 2017: A cross-sectional population based serosurvey. Lancet Glob Health 2019;7:e1065-73.
5.	Basu A, Jain P, Gangodkar SV, Shetty S, Ghosh K. Dengue 2 virus inhibits in vitro megakaryocytic colony formation and induces apoptosis in thrombopoietin-inducible megakaryocytic differentiation from cord blood CD34+cells. FEMS Immunol Med Microbiol 2008;53:46-51.
6.	Ghosh K, Gangodkar S, Jain P, Shetty S, Ramjee S, Poddar P, et al. Imaging the interaction between dengue 2 virus and human blood platelets using atomic force and electron microscopy. J Electron Microsc (Tokyo) 2008;57:113-8.
7.	Wichmann O, Gascon J, Schunk M, Puente S, Siikamaki H, Gjørup I, et al. Severe dengue virus infection in travelers: Risk factors and laboratory indicators. J Infect Dis 2007;195:1089-96.
8.	Trung DT, Thao le TT, Hien TT, Hung NT, Vinh NN, Hien PT, et al. Liver involvement associated with dengue infection in adults in Vietnam. Am J Trop Med Hyg 2010;83:774-80.
9.	Seneviratne SL, Malavige GN, de Silva HJ. Pathogenesis of liver involvement during dengue viral infections. Trans R Soc Trop Med Hyg 2006;100:608-14.
10.	Póvoa TF, Alves AM, Oliveira CA, Nuovo GJ, Chagas VL, Paes MV. The pathology of severe dengue in multiple organs of human fatal cases: Histopathology, ultrastructure and virus replication. PLoS One 2014;9:e83386.
11.	Fernando S, Wijewickrama A, Gomes L, Punchihewa CT, Madusanka SD, Dissanayake H, et al. Patterns and causes of liver involvement in acute dengue infection. BMC Infect Dis 2016;16:319.
12.	de Souza LJ, Nogueira RM, Soares LC, Soares CE, Ribas BF, Alves FP, et al. The impact of dengue on liver function as evaluated by aminotransferase levels. Braz J Infect Dis 2007;11:407-10.
13.	World Health Organisation. Dengue: Guidelines for Diagnosis, Treatment, Prevention and Control. Geneva, Switzerland: World Health Organisation; 2009.
14.	Wong M, Shen E. The utility of liver function tests in dengue. Ann Acad Med Singap 2008;37:82-3.
15.	Souza LJ, Alves JG, Nogueira RM, Gicovate Neto C, Bastos DA, Siqueira EW, et al. Aminotransferase changes and acute hepatitis in patients with dengue fever: Analysis of 1,585 cases. Braz J Infect Dis 2004;8:156-63.
16.	de Souza LJ, Martins AL, Paravidini PC, Nogueira RM, Gicovate Neto C, Bastos DA, et al. Hemorrhagic encephalopathy in dengue shock syndrome: A case report. Braz J Infect Dis 2005;9:257-61.
17.	Narasimhan D, Ponnusamy P, Sathish M. Analysis of liver function tests in dengue fever. Int J Adv Med 2018;5:47-9.
18.	Shastri PS, Gupta P, Kumar R. A prospective 3 year study of clinical spectrum and outcome of dengue fever in ICU from a tertiary care hospital in North India. Indian J Anaesth 2020;64:181-6. [Full text]
19.	Shivkar RR, Padwal MK, Vaidya AJ. Correlation of liver transaminases with platelet count in dengue patients from tertiary care hospital in Western India. Int J Curr Res Rev 2018;10:15.
20.	Wang XJ, Wei HX, Jiang SC, He C, Xu XJ, Peng HJ. Evaluation of aminotransferase abnormality in dengue patients: A meta analysis. Acta Trop 2016;156:130-6.
21.	Karoli R, Fatima J, Siddiqi Z, Kazmi KI, Sultania AR. Clinical profile of dengue infection at a teaching hospital in North India. J Infect Dev Ctries 2012;6:551-4.
22.	Itha S, Kashyap R, Krishnani N, Saraswat VA, Choudhuri G, Aggarwal R. Profile of liver involvement in dengue virus infection. Natl Med J India 2005;18:127-30.
23.	Md Sani SS, Han WH, Bujang MA, Ding HJ, Ng KL, Amir Shariffuddin MA. Evaluation of creatine kinase and liver enzymes in identification of severe dengue. BMC Infect Dis 2017;17:505.
24.	Priyangika DK, Premawansa G, Adikari M, Thillainathan S, Premawansa S, Jayamanne BD, et al. Predictive value of hepatic transaminases during febrile phase as a predictor of a severe form of Dengue: Analysis of adult Dengue patients from a tertiary care setting of Sri Lanka. BMC Res Notes 2021;14:251.