A CAJM article on Hepatic function tests done on children suffering from sickle cell anaemia.There is evidence in the literature suggesting that biochemical and morphological hepatic changes occur in sickle cell anaemia patients.1'7 It is however, uncertain whether or not these changes which occur during crisis are reversible. Earlier studies have demonstrated an impairment of liver functional integrity with a rise in serum transaminases, but the extent of the hepatic injury has not been documented.4,5 This study was conducted to assess the hepatic functional derangement that occurs during vaso-occlusive crisis using biochemical techniques, to document the extent of derangement, and whether or not there was recovery

Adedoyin, M.A.

Fagbule, D.

Ojuawo, A.

Central African Journal of Medicine

English

IDS OpenDocs

Vol. 40, No. 12 
ORIGINAL ARTICLES
CONTENTS December, 1994
Haematologic features of the human 
immunodeficiency virus (HIV) infection in Black 
children in H arare.........................................................
An investigation of the schistosomiasis 
transmission status in H arare .....................................
Hepatic function tests in children with sickle cell 
anaemia during vaso occlusive cr is is .......................
The Zimbabwe external quality assessment scheme 
(ZEQAS) in clinical chemistry: results o f the pilot 
programme ...................................................................
CASE REPORTS
Complete rectal prolapse in adults: a Tanzanian 
experience......................................................................
Delayed diagnosis o f retinoblastoma.......................
Bilateral fracture o f the femoral neck as a direct 
result o f electrocution shock .....................................
LETTERS TO THE EDITOR 
The gastroscope, labour intensive family planning 
and incentives................................................................
REVIEW ARTICLES
Hydatidiform m o l e ......................................................
BOOK REVIEW
Biological oxidants and antioxidants........................
JO Adewuyi, I C h itsik e .............................................................333
J Ndamba, MG Chidimu, M Zimba, E Gomo,
M M unjom a................................................................................. 337
A Ouawo, MA Adedoyin, D F agb u le ......................................342
WB Mujaji, HN Mazhindu, ZAR Gomo,
HT Marima-Matarira, C Samuwi, T Nyamayaro,
DG Bullock, JG R atc liff.............................................................345
Mr Aziz, NAA Mbembati............................................................ 349
SNN Nwosu, GSC Okoye, TO U l a s i ......................................353
L Nyoni, CR Saunders, AB Morar ......................................... 355
DAA V e r k u y l............................................................................. 356
P Z vandasara...............................................................  357
Y S N a i k ....................................................................................... 362
SUPPORTED BY CIMAS MEDICAL AID SOCIETY
CENTRAL AFRICAN
JOURNAL OF MEDICINE
Vol. 40, No. 12,1994
Hepatic function tests in 
children with sickle cell 
anaemia during vaso 
occlusive crisis
AOJUAWO, MA ADEDOYIN, D FAGBULE 
SUMMARY
Thirty children with sickle cell anaemia had their 
serum alanine aminotransferase, alkaline phosphatase, 
total protein, albumin and bilirubin, assayed during 
vaso-occlusive crisis and at recovery.
Alanine aminotransferase, alkaline phosphatase and 
bilirubin levels were significantly higher during crisis 
than at recovery, (p < 0,005) especially in the young 
patient However, the total protein and albumin levels 
were not significantly different in crisis and at recov­
ery.
Department o f Child Health 
University ofllorin  
PMB 1515 
Ilorin, Nigeria 
Correspondence to:
Dr A Ojuawo
A transient hepatic functional derangement during 
vaso-occlusive crisis is a probable explanation for the 
reported changes.
INTRODUCTION
There is evidence in the literature suggesting that bio­
chemical and morphological hepatic changes occur in 
sickle cell anaemia patients.1'7 It is however, uncertain 
whether or not these changes which occur during crisis 
are reversible. Earlier studies have demonstrated an 
impairment of liver functional integrity with a rise in 
serum transaminases, but the extent of the hepatic 
injury has not been documented.4,5 This study was 
conducted to assess the hepatic functional derange­
ment that occurs during vaso-occlusive crisis using 
biochemical techniques, to document the extent of 
derangement, and whether or not there was recovery.
MATERIALS AND METHODS
Sickle cell anaemia (SCA) patients whose haemoglobin 
electrophoresis is “SS” using the cellulose acetate 
paper were studied during vaso-occlusive crisis and at 
recovery. Serum levels of alanine aminotransaminase 
(ALT), alkaline phosphatase (ALP), total protein, al­
bumin and bilirubin were measured during crisis and at 
recovery, each SCA patient being its own control. 
Vaso-occlusive crisis is defined, for the purpose of this 
study, as painful crisis in any of the bones and abdomen 
without any organic cause apart from sickle cell anaemia. 
Recovery is defined as four weeks after painful crisis 
by which time the patient is totally symptom free.
Observing the rules of asepsis, venous blood was 
taken from all the SCA patients during vaso-occlusive 
crisis and at recovery and the blood samples were 
processed within two hours of collection.
Analytical method: Serum alanine aminotran­
saminase activity was analysed by the calorimetric 
method using 2-4 dinitrophenyl hydrazine.9 Aspartate 
aminotransferase activity was not assayed routinely in 
our laboratory.
Alkaline phosphatase was analysed by the colori­
metric method using phenlyphosphate as substrate.10 
Bilirubin was analysed by the Malloy and Evelyn 
method using methanol as an accelerator.11 Serum 
proteins were analysed by the BIURET method.17
Statistical analyses were done using appropriate 
methods (student’s t-test and correlation coefficients).
342
CENTRAL AFRICAN
JOURNAL OF MEDICINE
Vol. 40, No.12,1994
RESULTS
Thirty patients with sickle cell anaemia, 16 males and 
14 females were studied. The mean age was 8,95 years 
with a range of one to 18 years.
Table I shows the various enzyme levels both during 
the crises and recovery. The mean level of alanine
aminotransferase (ALT) during crises (84,5 iu/1) was 
significantly higher than in the steady state (14 iu/1) 
(p < 0,005). During crisis, 23 (76 pc) of the 30 SCA 
patients had raised enzyme levels (>15 iu/1) and only 
five (16 pc) still had raised levels at recovery. The 
young SCA patients had a higher value than the older 
ones during crises.
Table /: Mean serum levels o f alanine aminotransferase, alkaline phosphatase, total protein, albumin and 
bilirubin during crisis and at recovery.
Parameter Crisis (n = 30) Recovery (n = 30) t P
Alanine transaminase 48,5 ± 12,32 (10-98) 14 ± 5,26(4-32) 3,38 <0,005
(lu/l)
Alkaline phosphatase
(Iu/1)
128,5 ± 26,8(100-300) 98,4 ± 31,5 (72-180) 2,15 <0,025
Total protein 66,62 ± 9,75(60-72) 68,2 ±10,28 (62-76) 1.52 >0,05
(Gm/I)
Albumin (GmA) 32,2 ± 4,55(30-35) 34,0 ± 5,75(30-40) 1,15 >0,06
Total bilirubin 114,25 ± 23,5(39-396) 47,5 ±16,56 (18-88) 3,33 <0,25
(umol/l)
Conjugated bilirubin 
(umol/l)
87,8 ± 19,71 (20-221) 11,2 ±  5,52(0-32) 3,45 <0,001
Albumin/globulin ratio 0,935 0,935
The figures in bracket represents the ranges o f values. 
Each parameter has 58 degrees o f freedom.
Table II: The test values during crisis according to age groups.
Parameters 1 -6  years (n = 9) 7-12 years (n = 14) 13-18yrs(n = 7) r
Alanine Aminostransferase 54,24 ±14,601 43,67 ±10,612 40,50 ±8,80 0,898
(Iu/1)
Alkaline Phosphatase (Iu/1) 
Total Protein
138,25 ±23,936 127,2 ± 20,089 118 ±24,77 0,890
(Gm/I) 64,6 ±10,704 66,56 ±12,45 68,39 ±7,95 0,951
Albumin (Gm/I) 32,4 ±4,80 31,8 ± 4,706 27,67 ±2,388 0,903
Total Bilirubin 117,0 ±31,126 113,167 ±25,62 117,833 ±22,8 0,928
(umol/l)
Conj. Bilirubin 
(umol/l)
97,2 ±18,8 80,667 ±11,511 81,146 ±18,448 0,886
Correlation coefficient it  “r".
343
CENTRAL AFRICAN
JOURNAL OF MEDICINE
Vol. 40, No. 12,1994
Also, the mean alkaline phosphatase level (128 ± 
12,32) was significantly higher during crisis as com­
pared to the mean level (98,4 ± 31,5) at recovery (p < 
0,05). Again the levels were higher in younger SCA 
patients where compared to the older ones.
The difference between levels of total protein and 
albumin in both crisis and recovery were not signifi­
cantly different (p > 0,05). There was however, a slight 
rise in the level of'each which may be clinically 
important. Albumin/globulin ratio was less than one 
(0,935 and 0,995) in crisis and recovery phases respec­
tively (Table I).
The mean total serum bilirubin during crisis (114,25 
±23,5 umol/1) was significantly higher than at recovery 
(47,5 ± 16,75 umol/1): (p < 0,025) and the hyperbili- 
rubiacmia was predominantly conjugated.
Table II shows the effects of age on the various 
enzyme levels. The younger the patient the higher the 
level of alanine aminotransferase and alkaline phos­
phatase levels. The correlation coefficient for each 
(0,898, 0,890) was quite significant. The same trend 
was noted for serum albumin levels. However, for total 
protein, the reverse was the case. The correlation coef­
ficient of 0,951 was noted for total protein level. The 
younger the patient the lower the total protein.
DISCUSSION
The mechanism of hepatic injury in sickle cell disease 
is uncertain. There is a transient hepatic functional 
derangement during crisis .“•5 Barret-Connor emphasised 
the potential role of viral hepatitis observed in the 
group SCA patients she studied.13
In the group of children studied by us, alanine 
amino-transferase levels were higher during crisis, and 
these returned to normal at recovery. This finding is in 
agreement with earlier reports.3-5 That the levels of the 
aminotransferase returned to normal at recovery sug­
gest a transient hepatocytic injury during crisis. He­
patic necrosis in the region of the central vein has been 
described in adults with SCA at autopsies.2-6-7 While the 
extensive work of Bauer, et cdli supports hepatocelluar 
injury, findings of Omata et al'6 showed only acute or 
subacute infection but failed to show any evidence of 
hepatic necrosis.
The serum alanine aminotransferase was higher in 
the younger age group than in the older children with 
SCA which may suggest a more severe hepatocyte 
injury in the younger children with SCA. The reason 
for this phenomenon is not clear.
The alkaline phospatase levels were higher during 
crisis and more so in the younger age group. This 
finding is similar to that of Kaine and Udeoso4 and may 
be due to a transient intrahepatic cholestatis suggesting 
hepatocyte swelling.4-6-7 Cholelithiasis which may con­
tribute to hepatobiliary obstruction was recorded in 
only 4,2 pc of Nigerian SCA children studied.14 Since 
osseous activity in this age group is high, an assay of the 
isoenzymes of alkaline phosphatase would have thrown 
more light on the source of these raised enzyme levels 
during crisis. This question is being addressed in a 
separate study in our centre.
Serum protein levels did not show any significant 
difference during crisis and at recovery. This report is 
similar to the findings of Isichei3 and Kaine and Udeozo.4 
The relative similarity in the values during crisis and at 
recovery is probably related to the long half-life of the 
protein which will not change much during the short 
period of acute SCA crisis.
In conclusion, this study suggests a transient but 
reversible hepatic functional derangement during 
thrombotic crisis, which may be due to some degree of 
hepatocellular injury with intrahepatic. cbolestatitis. 
However, considering the chronic nature of the dis­
ease, the long term consequence of this probably re­
peated derangement on hepatic function remains to be 
ascertained.
ACKNOWLEDGEMENTS
We are grateful to Mr ‘Kunle Ojo for the secretarial 
assistance.
REFERENCES
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4. Kaine WN, Udeozo IOK. Sickle cell hepatic 
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6. Diggs LW. Pathology of sickle cell anaemia. 
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Hepatic function tests in children with sickle cell anaemia during vaso occlusive crisis.

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Hepatic function tests in children with sickle cell anaemia during vaso occlusive crisis.

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