New indicators in evaluation of hemolysis,elevated liver enzymes,and low platelet syndrome:A case-control study

BACKGROUND Indices such as the neutrophil-to-lymphocyte ratio(NLR),platelet-to-lymphocyte ratio(PLR),mean platelet volume(MPV),platelet distribution width(PDW),and red cell distribution width(RDW)are considered new markers of the systemic inflammatory response(SIR),and have been widely implemented for the diagnosis of patients with inflammatory diseases.These new indicators have also been widely investigated in preeclampsia(PE)but less analyzed in hemolysis,elevated liver enzymes,and low platelet(HELLP)syndrome.AIM To compare SIR markers among HELLP patients,PE only patients,and healthy gravidae.METHODS This retrospective case-control study enrolled 630 cases,including 210 patients with HELLP syndrome(HELLP group),210 patients with only PE(PE group)and 210 healthy gravidae(control group).The three groups were matched by age,parity,status of assisted reproduction,and multiple pregnancies.Birthweight,gestational age at complete blood count collection,gestational age at delivery,mode of delivery,etc.were recorded.The main indices as NLR,PLR,MPV,PDW,and RDW among the groups were compared,as well as some secondary outcomes including neutrophil,platelets,and hemoglobin.RESULTS The NLR(6.4 vs 4.3 vs 3.5),MPV(11.9 vs 11.2 vs 10.7),PDW(16.4 vs 13.3 vs 14.2),leukocyte(12.4×10^(9)/L vs 9.7×10^(9)/L vs 8.7×10^(9)/L)and neutrophil count(9.9×10^(9)/L vs 7.3×10^(9)/L vs 6.1×10^(9)/L)were highest in the HELLP group,lower in the PE group,and lowest in the control group.Both the overall comparisons between the three groups(all bP<0.01)and pairwise comparisons between every two groups elicited statistically significant differences(all dP<0.01,except control vs PE:cP<0.05 in PDW).The average lymphocyte counts were 1.4(1.1,2.0)×10^(9)/L in the HELLP group,1.6(1.3,2.0)×10^(9)/L in the PE group and 1.7(1.4,2.0)×10^(9)/L in the control group.The overall comparison of lymphocyte count within the three groups had statistically significant differences(P=0.000).The pairwise comparisons between every two groups demonstrated that the HELLP group had a lower lymphocyte count than both the PE(P=0.019)and control groups(P=0.000),but the difference between the PE and control groups was not statistically significant(P=0.432).The overall comparisons on platelet counts and the PLR among these three groups also showed statistically significant differences(both P=0.000),from low to high being those in the HELLP group(43.4×10^(9)/L,64.0),control group(180.5×10^(9)/L,103.6)and PE group(181.5×10^(9)/L,112.8).Pairwise comparisons of neither index displayed statistically significant differences between the PE and control groups(both P>0.05),while the differences in the two indices between the HELLP group and the two other groups were still statistically significant(all P=0.000).RDW values were highest in the HELLP group(14.5%[13.6,15.3]),lower in the control group(14.1%[13.5,14.8])and lowest in the PE group(13.9%[13.4,14.9]).The difference between the PE and control group did not show statistical significance(P=1.000),while RDW values in the HELLP group were higher than those in the other two groups(cP<0.05 vs control,dP<0.01 vs PE).CONCLUSION SIR markers such as NLR,RDW,MPV,and PDW were increased and PLR was decreased in HELLP.These SIR markers may become new indicators in the evaluation of HELLP syndrome.

Perihepatic adhesions: An unusual complication of hemolysis, elevated liver enzymes and low platelet syndrome

We present a case of symptomatic perihepatic adhesions,which developed after a pregnancy complicated by hemolysis,elevated liver enzymes and low platelet(HELLP)syndrome,in which a subcapsular liver hematoma occurred.Our patient presented with complaints of persistent,severe right-sided upper abdominal pain.The complaints developed gradually,one year after a pregnancy that had been complicated by HELLP syndrome with a subcapsular liver hematoma.The hematoma had resolved spontaneously.An upperabdominal magnetic resonance imaging revealed a density between liver and diaphragm at the site of the former subcapsular hematoma,suspect of perihepatic adhesions.The presence of perihepatic adhesions was confirmed during a laparoscopy and treated by adhesiolysis in the same session.The adhesions may have developed in response to the degradation process of the subcapsular liver hematoma during conservative treatment.This case of perihepatic adhesions may therefor be the first presentation of a long term sequel of subcapsular liver hematoma in HELLP syndrome.

Liver stiffness reversibly increases during pregnancy and independently predicts preeclampsia

AIM To study liver stiffness(LS) during pregnancy and its association with complications during pregnancy.METHODS In this observational, diagnostic study, 537 pregnant women were prospectively enrolled at the Department of Obstetrics and Gynecology, University hospital Heidelberg and Salem Medical Center. LS was measured using the Fibroscan device(Echosens, Paris) in all women and in 41 cases 24 h after delivery. Clinical and morphological data were recorded and abdominal ultrasound and standard laboratory tests were performed. No complications were observed in 475 women(controls) while preeclampsia and intrahepatic cholestasis of pregnancy(ICP) developed in 22 and 40 women, respectively.RESULTS In controls, LS increased significantly from initially 4.5 ± 1.2 kPa in the second trimester to 6.0 ± 2.3 kPa(P < 0.001) in the third trimester. In the third trimester, 41% of women had a LS higher than 6 kPa. Elevated LS in controls was significantly correlated with alkaline phosphatase, leukocytes, gestational age and an increase in body weight and body mass index(BMI). In women with pregnancy complications, LS was significantly higher as compared to controls(P < 0.0001). Moreover, in multivariate analysis, LS was an independent predictor for preeclampsia with an odds ratio of 2.05(1.27-3.31) and a cut-off value of 7.6 kPa. In contrast, ICP could not be predicted by LS. Finally, LS rapidly decreased in all women within 24 h after delivery from 7.2 ± 3.3 kPa down to 4.9 ± 2.2 kPa(P < 0.001).CONCLUSION During pregnancy, LS significantly and reversibly increases in the final trimester of pregnant women without complications. In women with preeclampsia, LS is significantly elevated and an independent noninvasive predictor.

Association of autoimmune hepatitis and systemic lupus erythematodes:A case series and review of the literature

Liver test abnormalities have been described in up to 60% of patients with systemic lupus erythematodes(SLE) at some point during the course of their disease.Prior treatment with potentially hepatotoxic drugs or viral hepatitis is commonly considered to be the main cause of liver disease in SLE patients.However,in rare cases elevated liver enzymes may be due to concurrent autoimmune hepatitis(AIH).To distinguish whether the patient has primary liver disease with associated autoimmune clinical and laboratory features resembling SLE- such as AIH- or the elevation of liver enzymes is a manifestation of SLE remains a difficult challenge for the treating physician.Here,we present six female patients with complex autoimmune disorders and hepatitis.Patient charts were reviewed in order to investigate the complex relationship between SLE and AIH.All patients had coexisting autoimmune disease in their medical history.At the time of diagnosis of AIH,patients presented with arthralgia,abdominal complaints,cutaneous involvement and fatigue as common symptoms.All patients fulfilled the current diagnostic criteria of both,AIH and SLE.Remission of acute hepatitis was achieved in all cases after the initiation of immunosuppressive therapy.In addition to this case study a literature review was conducted.

Hypertensive disorders in pregnancy

Renal injury or failure may occur in the context of pre-gnancy requiring special considerations with regard to fetal and maternal health. The condition of pregnancy itself may be a major factor in such injuries. In addition,for many young women previously known to be healthy, pregnancy may be the frst presentation for routine urine and blood testing which may yield previously subclinical renal disease. As such, pregnancy may add complexity to considerations in the management of renal disease presenting coincidentally requiring knowledge of the physiologic changes and potential renal disorders that may be encountered during pregnancy.

Hepatobiliary manifestations in children with inflammatory bowel disease:A single-center experience in a low/middle income country

BACKGROUNDThere has been a worldwide increase in the reported incidence of inflammatorybowel disease (IBD) in children over the past 2-3 decades. The hepatobiliary (HB)manifestations of IBD have been well-studied in children in industrialized anddeveloped countries but are infrequently reported in low- and middle-incomecountries (LMIC) such as Egypt.AIMTo determine the prevalence of the HB manifestations in a cohort of Egyptianchildren with IBD.METHODSThis cross-sectional observational study was carried out over a period of 6 mo(between June 2013 to December 2013, at the Paediatric Hepatology andGastroenterology Units of Cairo University Children's Hospital, which is thelargest paediatric tertiary care centre in the country.RESULTSThe study included 48 patients with confirmed IBD based upon clinical,laboratory, endoscopic and histopathological features, 29 (60.4%) were male.Twenty-four patients (50%) had ulcerative colitis (UC), 11 (22.9%) had Crohn'sdisease (CD) and 13 (27.1%) had unclassified-IBD (IBD-U), which was formerlyknown as indeterminate colitis. The mean age of the patients at the time ofpresentation was 8.14 (± SD 4.02) years and the mean age at the time of studyenrolment was 10.16 (± SD 4.19) years. All patients were screened for HBmanifestations by physical examination, liver function tests, imaging and liver biopsy when indicated. HB disorders were confirmed in 13 patients (27.1%).Transaminases were elevated in 3 patients (6.3%). Two patients (4.2%) hadelevated biliary enzymes (one was diagnosed as primary sclerosing cholangitis(PSC) and the other was diagnosed with PSC/autoimmune hepatitis overlapsyndrome and the third patient had hepatitis C virus infection. Ten patients(20.8%) had bright echogenic liver on ultrasound suggesting fatty infiltration as asequel of malnutrition or medication toxicity.CONCLUSIONThe commonest HB disorders in Egyptian children with IBD were abnormal liverfunction tests, fatty infiltration and PSC. These HB manifestations in paediatricpatients in LMIC may be relatively more common than in industrializedcountries. Therefore, IBD patients in LMIC should be meticulously screened forliver disease to allow prompt diagnosis and management.