Hypokalemia in Patients with COVID-19

The ZNF717-rs2918520 genotype contributes to COVID-19 severity: a Taiwanese cohort study

BACKGROUND

Coronavirus disease 2019 (COVID-19) has been a challenging pandemic since late 2019 and patients with COVID-19-related severe respiratory failure associated with high mortality rates worldwide. Genetic information such as single nucleotide polymorphisms (SNPs) serves as a predictor or prognostic factor in disease development and cancer progression. This study aimed to explore the clinical associations of SNPs with mild and severe COVID-19 symptoms in the Taiwanese population.

METHODS

SARS-CoV-2-infected patients in pilot cohort study (cohort 1, n = 39) and validation cohort (cohort 2, n = 71) were enrolled. The clinical significance of SNPs in those patients with mild and severe symptoms was investigated by whole exon sequencing, polymerase chain reaction and Sanger sequencing.

RESULTS

The current study investigated Taiwanese patients with COVID-19. We found that clinical parameters such as age, aspartate aminotransferase, blood urea nitrogen, C-reactive protein, ferritin, and segment were positively associated with severe COVID-19 symptoms but that albumin, lymphocytes, and basophils correlated negatively with severe symptoms in two independent cohorts. By conducting whole-exome sequencing, we identified a novel SNP, ZNF717-rs2918520, the GG genotype of which was significantly associated with severe symptoms in COVID-19 patients.

CONCLUSIONS

Our findings highlight that the ZNF717-rs2918520 GG genotype may serve as a predictor for evaluating the severity of COVID-19 in Taiwan.

Trends of common laboratory biomarkers after SARS-CoV-2 infection

BACKGROUND

Most studies that explore the long-term effects of COVID-19 are based on subjectively reported symptoms, while laboratory-measured biomarkers are mainly examined in studies of relatively small cohorts. This study investigates the long-term effects of SARS-CoV-2 infection on common laboratory biomarkers.

METHODS

We utilized a retrospective cohort of SARS-CoV-2 infected individuals and rigorously matched controls based on demographic and clinical characteristics, examining 63 common laboratory biomarkers. Additional lab-specific cohorts were matched with an additional criterion of baseline biomarker values. Differences in biomarkers over a 12-month follow-up were analyzed using standardized mean difference-in-differences.

RESULTS

The general cohort included 361,061 matched pairs, with 26M laboratory results. The effects on most biomarkers lasted 1-4 months and were consistent with anticipated changes after acute viral infections. Some biomarkers presented prolonged effects, consistent across the general and lab-specific cohorts. One group of such findings included a 7-8 month decrease in WBC counts, mainly driven by decreased counts of neutrophils, monocytes, and basophils. Potassium levels were decreased for 3-5 months. Vaccinated individuals' data suggested potentially smaller effects on WBCs, but cohort sizes limited this analysis.

CONCLUSIONS

This study explores SARS-CoV-2 infection effects on common laboratory biomarkers, characterizing the direction and duration of these effects on the largest infected cohort to date. The effects of most biomarkers resolve in the first months following infection. The most notable longer-lasting effects involved the immune system. Further research is required to characterize the magnitude of these effects among specific individuals.

Semi-quantitative CT score reflecting the degree of pulmonary infection as a risk factor of hypokalemia in COVID-19 patients: a cross-sectional study

Background

Hypokalemia is a common electrolyte disorder observed in patients afflicted with coronavirus disease 2019 (COVID-19). When COVID-19 is accompanied by pulmonary infection, chest computed tomography (CT) is the preferred diagnostic modality. This study aimed to explore the relationship between CT semi-quantitative score reflecting the degree of pulmonary infection and hypokalemia from COVID-19 patients.

Methods

A single-center, cross-sectional study was conducted to investigate patients diagnosed with COVID-19 between December 2022 and January 2023 who underwent chest CT scans upon admission revealing typical signs. These patients were categorized into two groups based on their blood potassium levels: the normokalemia group and the hypokalemia group. Medical history, symptoms, vital signs, laboratory data, and CT severity score were compared. Binary regression analysis was employed to identify risk factors associated with hypokalemia in COVID-19 patients with pulmonary infection.

Results

A total of 288 COVID-19 patients with pulmonary infection were enrolled in the study, of which 68 (23.6%) patients had hypokalemia. The CT severity score was found to be higher in the hypokalemia group compared to the normokalemia group [4.0 (3.0-5.0) vs. 3.0 (2.0-4.0), p = 0.001]. The result of binary logistic regression analysis revealed that after adjusting for sex, vomiting, sodium, and using potassium-excretion diuretics, higher CT severity score was identified as an independent risk factor for hypokalemia (OR = 1.229, 95% CI = 1.077-1.403, p = 0.002).

Conclusion

In this cohort of patients, semi-quantitative CT score reflecting the degree of pulmonary infection may serve as a risk factor of hypokalemia in COVID-19 patients.

The Relationship between the Laboratory Biomarkers of SARS-CoV-2 Patients with Type 2 Diabetes at Discharge and the Severity of the Viral Pathology

In this study, we evaluated the discharge status of patients with type 2 diabetes mellitus and SARS-CoV-2 infection, focusing on the inflammatory profile through biomarkers such as procalcitonin, CRP, LDH, fibrinogen, ESR, and ferritin, as well as electrolyte levels and the prior diagnosis of diabetes or its identification at the time of hospitalization. We assessed parameters at discharge for 45 patients admitted to the Clinical Hospital "Gavril Curteanu" Oradea between 21 October 2021, and 31 December 2021, randomly selected, having as the main inclusion criteria the positive RT-PCR rapid antigen test for viral infection and the diagnosis of type 2 diabetes. At discharge, patients with type 2 diabetes registered significantly lower mean procalcitonin levels among those who survived compared to those who died from COVID-19. In our study, ferritin and hemoglobin values in individuals with type 2 diabetes were outside the reference range at discharge and correlated with severe or moderate forms of COVID-19 infection. Additionally, elevated ferritin levels at discharge were statistically associated with hypokalemia and elevated levels of ESR at discharge. Another strong statistically significant correlation was identified between high CRP levels at discharge, strongly associated (p < 0.001) with elevated LDH and fibrinogen levels in patients with type 2 diabetes and SARS-CoV-2 viral infection. The increase in CRP was inversely statistically associated with the tendency of serum potassium to decrease at discharge in patients with type 2 diabetes and COVID-19. Identifying type 2 diabetes metabolic pathology at the time of hospitalization for SARS-CoV-2 infection, compared to pre-infection diabetes diagnosis, did not significantly influence the laboratory parameter status at the time of discharge. At the discharge of patients with type 2 diabetes and viral infection with the novel coronavirus, procalcitonin was significantly reduced in those who survived COVID-19 infection, and disease severity was significantly correlated with hyperferritinemia and decreased hemoglobin at discharge. Hyperferritinemia in patients with type 2 diabetes and COVID-19 at discharge was associated with hypokalemia and persistent inflammation (quantified by ESR at discharge). The low number of erythrocytes at discharge is associated with maintaining inflammation at discharge (quantified by the ESR value).

Sambou Bamboo salt™ down-regulates the expression levels of angiotensin-converting enzyme 2 in activated human mast cells

Mast cells have a detrimental impact on coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Sambou Bamboo salt™ (BS) suppresses mast cell-mediated inflammatory response and enhances immunity. In this study, we investigated the regulatory effects of BS on expression of angiotensin-converting enzyme 2 (ACE2) and transmembrane protease/serine subfamily member 2 (TMPRSS2) in human mast cell line (HMC)-1 cells. BS resulted in significant reductions in expression levels of ACE2 and TMPRSS2 in activated HMC-1 cells. Levels of tryptase were reduced by BS. In addition, BS blocked activation of activator protein 1 (AP-1), c-Jun NH2-terminal kinases (JNK), p38, and phosphatidylinositide-3-kinase (PI3K) in activated HMC-1 cells. Therefore, these results show that BS reduces levels of ACE2, TMPRSS2, and tryptase by inhibiting AP-1/JNK/p38/PI3K signaling pathways in mast cells. These findings can serve as valuable foundational data for the development of therapeutic agents aimed at preventing SARS-CoV-2 infection.

Antiviral Use in Mild-to-Moderate SARS-CoV-2 Infections during the Omicron Wave in Geriatric Patients

(1) Background: Geriatric patients are at high risk of complications of Coronavirus disease-2019 (COVID-19) and are good candidates for antiviral drugs. (2) Methods: A retrospective study of electronic health records (EHRs) aiming to describe antiviral (nirmatrelvir and ritonavir (nirmatrelvir/r) or remdesivir) use, drug-drug interactions (DDIs) and adverse drug reactions (ADRs) in elderly patients (75 and over), hospitalized with mild-to-moderate COVID-19 between July 2022 and June 2023. (3) Results: Out of 491 patients (mean age: 86.9 years), 180 (36.7%) received nirmatrelvir/r, 78 (15.9%) received remdesivir, and 233 (47.4%) received no antiviral therapy. No association was found between the choice of antiviral and the demographic or medical data. No serious ADR was observed. Nirmatrelvir/r dosage adjustment was inadequate in 65% of patients with renal impairment. In total, 128 patients (71%) on nirmatrelvir/r had potential pharmacokinetic DDIs, with 43 resulting in a possibly related ADR. In the remdesivir group, pharmacodynamic DDIs were more frequent, with QTc prolongation risk in 56 patients (72%). Only 20 patients underwent follow-up ECG, revealing QTc prolongation in 4. (4) Conclusions: There is an underutilization of antivirals despite their justified indications. Nirmatrelvir/r dosage was rarely adjusted to renal function. Dose adjustments and closer monitoring are needed due to the high risk of drug interactions.

Case report of scrub typhus complicated by hypokalemia and multiple organ dysfunction syndrome

CONTEXT

Scrub typhus, caused by Orientia tsutsugamushi, has a wide range of clinical manifestations, including meningoencephalitis, acute renal failure, pneumonitis, myocarditis, and septic shock. However, there are no documented cases of scrub typhus with hypokalemia. In this report, we present a case of scrub typhus with hypokalemia and multiple organ failure syndrome, highlighting the importance of electrolyte imbalance in patients with scrub typhus.

CASE REPORT

A 59-year-old woman presented to the emergency department with abdominal pain that had been present for 1 day. On admission, the physical examination and laboratory test results indicated that the patient had renal, liver, and circulatory failure, and hypokalemia. She developed meningitis and disseminated intravascular coagulation during hospitalization. She recovered with appropriate management, and was discharged on day 17.

CONCLUSION

This report highlights the potential for atypical presentations of scrub typhus, including a previously undocumented association with hypokalemia. Although the contribution of hypokalemia to the patient's clinical course remains uncertain, this case underscores the importance of considering electrolyte imbalance in the management of patients with scrub typhus. Further research is warranted to better understand the relationship between scrub typhus and electrolyte imbalance.

Real-time prognostic biomarkers for predicting in-hospital mortality and cardiac complications in COVID-19 patients

Hospitalized patients with Coronavirus disease 2019 (COVID-19) are highly susceptible to in-hospital mortality and cardiac complications such as atrial arrhythmias (AA). However, the utilization of biomarkers such as potassium, B-type natriuretic peptide, albumin, and others for diagnosis or the prediction of in-hospital mortality and cardiac complications has not been well established. The study aims to investigate whether biomarkers can be utilized to predict mortality and cardiac complications among hospitalized COVID-19 patients. Data were collected from 6,927 hospitalized COVID-19 patients from March 1, 2020, to March 31, 2021 at one quaternary (Henry Ford Health) and five community hospital registries (Trinity Health Systems). A multivariable logistic regression prediction model was derived using a random sample of 70% for derivation and 30% for validation. Serum values, demographic variables, and comorbidities were used as input predictors. The primary outcome was in-hospital mortality, and the secondary outcome was onset of AA. The associations between predictor variables and outcomes are presented as odds ratio (OR) with 95% confidence intervals (CIs). Discrimination was assessed using area under ROC curve (AUC). Calibration was assessed using Brier score. The model predicted in-hospital mortality with an AUC of 90% [95% CI: 88%, 92%]. In addition, potassium showed promise as an independent prognostic biomarker that predicted both in-hospital mortality, with an AUC of 71.51% [95% Cl: 69.51%, 73.50%], and AA with AUC of 63.6% [95% Cl: 58.86%, 68.34%]. Within the test cohort, an increase of 1 mEq/L potassium was associated with an in-hospital mortality risk of 1.40 [95% CI: 1.14, 1.73] and a risk of new onset of AA of 1.55 [95% CI: 1.25, 1.93]. This cross-sectional study suggests that biomarkers can be used as prognostic variables for in-hospital mortality and onset of AA among hospitalized COVID-19 patients.

Utilizing machine learning for survival analysis to identify risk factors for COVID-19 intensive care unit admission: A retrospective cohort study from the United Arab Emirates

BACKGROUND

The current situation of the unprecedented COVID-19 pandemic leverages Artificial Intelligence (AI) as an innovative tool for addressing the evolving clinical challenges. An example is utilizing Machine Learning (ML) models-a subfield of AI that take advantage of observational data/Electronic Health Records (EHRs) to support clinical decision-making for COVID-19 cases. This study aimed to evaluate the clinical characteristics and risk factors for COVID-19 patients in the United Arab Emirates utilizing EHRs and ML for survival analysis models.

METHODS

We tested various ML models for survival analysis in this work we trained those models using a different subset of features extracted by several feature selection methods. Finally, the best model was evaluated and interpreted using goodness-of-fit based on calibration curves,Partial Dependence Plots and concordance index.

RESULTS

The risk of severe disease increases with elevated levels of C-reactive protein, ferritin, lactate dehydrogenase, Modified Early Warning Score, respiratory rate and troponin. The risk also increases with hypokalemia, oxygen desaturation and lower estimated glomerular filtration rate and hypocalcemia and lymphopenia.

CONCLUSION

Analyzing clinical data using AI models can provide vital information for clinician to measure the risk of morbidity and mortality of COVID-19 patients. Further validation is crucial to implement the model in real clinical settings.

Potassium intake: the Cinderella electrolyte

Dietary guidelines recommend intake targets for some essential minerals, based on observational and experimental evidence relating mineral intake levels to health outcomes. For prevention of cardiovascular disease, reducing sodium intake and increasing potassium intake are the principal tools. While reducing sodium intake has received greatest public health priority, emerging evidence suggests that increasing potassium intake may be a more important target for cardiovascular prevention. Increased potassium intake reduces blood pressure and mitigates the hypertensive effects of excess sodium intake, and the recent large Phase III SSaSS trial reported that increasing potassium intake (and reducing sodium intake) in populations with low potassium intake and high sodium intake, through salt substitution (25% KCl, 75%NaCl), reduces the risk of stroke in patients at increased cardiovascular risk. As key sources of potassium intake include fruit, vegetables, nuts, and legumes, higher potassium intake may be associated with healthy dietary patterns. The current review makes the case that increasing potassium intake might represent a more advantageous dietary strategy for prevention of cardiovascular disease. Future research should focus on addressing the independent effect of potassium supplementation in populations with low or moderate potassium intake, and determine effective strategies to increase potassium intake from diet.

New-onset atrial fibrillation among COVID-19 patients: A narrative review

Over the last three years, research has focused on examining cardiac issues arising from coronavirus disease 2019 (COVID-19) infection, including the emergence of new-onset atrial fibrillation (NOAF). Still, no clinical study was conducted on the persistence of this arrhythmia after COVID-19 recovery. Our objective was to compose a narrative review that investigates COVID-19-associated NOAF, emphasizing the evolving pathophysiological mechanisms akin to those suggested for sustaining AF. Given the distinct strategies involved in the persistence of atrial AF and the crucial burden of persistent AF, we aim to underscore the importance of extended follow-up for COVID-19-associated NOAF. A comprehensive search was conducted for articles published between December 2019 and February 11, 2023, focusing on similarities in the pathophysiology of NOAF after COVID-19 and those persisting AF. Also, the latest data on incidence, morbidity-mortality, and management of NOAF in COVID-19 were investigated. Considerable overlaps between the mechanisms of emerging NOAF after COVID-19 infection and persistent AF were observed, mostly involving reactive oxygen pathways. With potential atrial remodeling associated with NOAF in COVID-19 patients, this group of patients might benefit from long-term follow-up and different management. Future cohort studies could help determine long-term outcomes of NOAF after COVID-19.

Hematological and Biochemical Laboratory Parameters in COVID-19 Patients: A Retrospective Modeling Study of Severity and Mortality Predictors

Background

It is well known that laboratory markers could help in identifying risk factors of severe illness and predicting outcomes of diseases. Here, we performed a retrospective modeling study of severity and mortality predictors of hematological and biochemical laboratory parameters in Iranian COVID-19 patients.

Methods

Data were obtained retrospectively from medical records of 564 confirmed Iranian COVID-19 cases. According to the disease severity, the patients were categorized into two groups (severe or nonsevere), and based on the outcome of the disease, patients were divided into two groups (recovered or deceased). Demographic and laboratory data were compared between groups, and statistical analyses were performed to define predictors of disease severity and mortality in the patients.

Results

The study identified a panel of hematological and biochemical markers associated with the severe outcome of COVID-19 and constructed different predictive models for severity and mortality. The disease severity and mortality rate were significantly higher in elderly inpatients, whereas gender was not a determining factor of the clinical outcome. Age-adjusted white blood cells (WBC), platelet cells (PLT), neutrophil-to-lymphocyte ratio (NLR), red blood cells (RBC), hemoglobin (HGB), hematocrit (HCT), erythrocyte sedimentation rate (ESR), mean corpuscular hemoglobin (MCHC), blood urea nitrogen (BUN), and creatinine (Cr) also showed high accuracy in predicting severe cases at the time of hospitalization, and logistic regression analysis suggested grouped hematological parameters (age, WBC, NLR, PLT, HGB, and international normalized ratio (INR)) and biochemical markers (age, BUN, and lactate dehydrogenase (LDH)) as the best models of combined laboratory predictors for severity and mortality.

Conclusion

The findings suggest that a panel of several routine laboratory parameters recorded on admission could be helpful for clinicians to predict and evaluate the risk of disease severity and mortality in COVID-19 patients.

Clinical outcomes of COVID-19 in hemodialysis patients

Background

The coronavirus disease 2019 (COVID-19) is known for its effects on the respiratory system. Three years after the pandemic morbid and mortal consequences, growing evidence is showing that the disease also has adverse outcomes and complications on additional organs including the kidneys. This study aims at investigating the effects of COVID-19 on hemodialysis patients receiving services at Palestine Medical Complex (PMC) kidney dialysis department, and to identify mortality related risk factors.

Methods

In April 2022, data was collected using the electronic medical records system for the dialysis department at PMC. The study included all PMC hemodialysis patients that were infected with COVID-19 between January 2020-April 2022. The collected data included patient demographics, clinical features, laboratory tests, dialysis frequency and the disease outcome.

Results

The results showed that the patients' outcomes and dialysis frequency were impacted by their blood urea nitrogen (BUN), serum creatinine (SCr) and calcium levels. About one third of the study population died after being infected with COVID-19. The frequency of dialysis was also affected by the presence of comorbidities like hypertension, diabetes mellitus (DM) and myocardial infarction (MI).

Conclusion

This study found that there was a high mortality rate within the hemodialysis patients infected with COVID-19. Having comorbidities affected the frequency of dialysis following COVID-19 infection. Dialysis patients should be protected from infections such as COVID-19 and their comorbidities should be monitored and kept under control as much as possible.

Efficacy and safety of SIM0417 (SSD8432) plus ritonavir for COVID-19 treatment: a randomised, double-blind, placebo-controlled, phase 1b trial

Background

SIM0417 (SSD8432) is an orally administered coronavirus main proteinase (3CL^pro) inhibitor with potential anti-SARS-CoV-2 activity. This study aimed to evaluate the efficacy and safety of SIM0417 plus ritonavir (a pharmacokinetic enhancer) in adults with COVID-19.

Methods

This was a randomised, double-blind, placebo-controlled, phase 1b study in China. Adults with asymptomatic infection, mild or moderate COVID-19 were randomly assigned (3:3:2) to receive either 750 mg SIM0417 plus 100 mg ritonavir, 300 mg SIM0417 plus 100 mg ritonavir or placebo every 12 h for 10 doses. The main efficacy endpoints included SARS-CoV-2 viral load, proportion of participants with positive SARS-CoV-2 nucleic acid test and time to alleviation of COVID-19 symptoms. This trial is registered with ClinicalTrials.gov, NCT05369676.

Findings

Between May 12 and August 29, 2022, 32 participants were enrolled and randomised to high dose group (n = 12), low dose group (n = 12) or placebo (n = 8). The viral load change from baseline in high dose group was statistically lower compared with placebo, with a maximum mean difference of -2.16 ± 0.761 log₁₀ copies/mL (p = 0.0124) on Day 4. The proportion of positive SARS-CoV-2 in both active groups were lower than the placebo. The median time to sustained alleviation of COVID-19 symptoms was 2.0 days in high dose group versus 6.0 days in the placebo group (HR = 3.08, 95% CI 0.968-9.818). SIM0417 plus ritonavir were well tolerated with all adverse events in grade 1.

Interpretation

SIM0417 plus ritonavir was generally well tolerated. The efficacy of SIM0417 showed a monotonic dose-response relationship, and the 750 mg SIM0417 plus 100 mg ritonavir was selected as the recommended clinical dose.

Funding

The study was funded by Jiangsu Simcere Pharmaceutical Co., Ltd.

Dietary anions control potassium excretion: it is more than a poorly absorbable anion effect

The urinary potassium (K+) excretion machinery is upregulated with increasing dietary K+, but the role of accompanying dietary anions remains inadequately characterized. Poorly absorbable anions, including [Formula: see text], are thought to increase K+ secretion through a transepithelial voltage effect. Here, we tested if they also influence the K+ secretion machinery. Wild-type mice, aldosterone synthase (AS) knockout (KO) mice, or pendrin KO mice were randomized to control, high-KCl, or high-KHCO3 diets. The K+ secretory capacity was assessed in balance experiments. Protein abundance, modification, and localization of K+-secretory transporters were evaluated by Western blot analysis and confocal microscopy. Feeding the high-KHCO3 diet increased urinary K+ excretion and the transtubular K+ gradient significantly more than the high-KCl diet, coincident with more pronounced upregulation of epithelial Na+ channels (ENaC) and renal outer medullary K+ (ROMK) channels and apical localization in the distal nephron. Experiments in AS KO mice revealed that the enhanced effects of [Formula: see text] were aldosterone independent. The high-KHCO3 diet also uniquely increased the large-conductance Ca2+-activated K+ (BK) channel β4-subunit, stabilizing BKα on the apical membrane, the Cl-/[Formula: see text] exchanger, pendrin, and the apical KCl cotransporter (KCC3a), all of which are expressed specifically in pendrin-positive intercalated cells. Experiments in pendrin KO mice revealed that pendrin was required to increase K+ excretion with the high-KHCO3 diet. In summary, [Formula: see text] stimulates K+ excretion beyond a poorly absorbable anion effect, upregulating ENaC and ROMK in principal cells and BK, pendrin, and KCC3a in pendrin-positive intercalated cells. The adaptive mechanism prevents hyperkalemia and alkalosis with the consumption of alkaline ash-rich diets but may drive K+ wasting and hypokalemia in alkalosis.NEW & NOTEWORTHY Dietary anions profoundly impact K+ homeostasis. Here, we found that a K+-rich diet, containing [Formula: see text] as the counteranion, enhances the electrogenic K+ excretory machinery, epithelial Na+ channels, and renal outer medullary K+ channels, much more than a high-KCl diet. It also uniquely induces KCC3a and pendrin, in B-intercalated cells, providing an electroneutral KHCO3 secretion pathway. These findings reveal new K+ balance mechanisms that drive adaption to alkaline and K+-rich foods, which should guide new treatment strategies for K+ disorders.

Integrative analysis of functional genomic screening and clinical data identifies a protective role for spironolactone in severe COVID-19

We demonstrate that integrative analysis of CRISPR screening datasets enables network-based prioritization of prescription drugs modulating viral entry in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by developing a network-based approach called Rapid proXimity Guidance for Repurposing Investigational Drugs (RxGRID). We use our results to guide a propensity-score-matched, retrospective cohort study of 64,349 COVID-19 patients, showing that a top candidate drug, spironolactone, is associated with improved clinical prognosis, measured by intensive care unit (ICU) admission and mechanical ventilation rates. Finally, we show that spironolactone exerts a dose-dependent inhibitory effect on viral entry in human lung epithelial cells. Our RxGRID method presents a computational framework, implemented as an open-source software package, enabling genomics researchers to identify drugs likely to modulate a molecular phenotype of interest based on high-throughput screening data. Our results, derived from this method and supported by experimental and clinical analysis, add additional supporting evidence for a potential protective role of the potassium-sparing diuretic spironolactone in severe COVID-19.

Evaluation of safety and effectiveness of remdesivir in treating COVID-19 patients after emergency use authorization study

Background: This study aimed to determine the real-world safety and effectiveness of remdesivir in hospitalized adult COVID-19 patients with moderate-to-critical disease in Indonesia. Methods: A multicenter, retrospective cohort study was conducted at four COVID-19 referral hospitals in Jakarta. A total of 587 patients were included, of whom 243 received remdesivir within 72 h of admission. The safety endpoints were the proportions of patients with any adverse event (AE), any grade 3 AE, and AE of each system organ class. The effectiveness endpoints were ICU admission >24 h from baseline, live discharge and mortality at day 14, live discharge and mortality at day 28, and virologic conversion. Patients who received remdesivir within 72 h of admission were considered the treatment group, and those who did not were the control group. Multivariate adjustments were performed using a modified Poisson regression. Results: The study found no significant differences in safety endpoints between the two groups. However, the effectiveness endpoints showed that remdesivir was associated with a decreased risk of ICU admission >24 h from baseline (RR 0.71, 95% CI 0.52-0.96), an increased probability of live discharge at day 14 (RR 1.37, 95% CI 1.08-1.74), and an increased probability of live discharge at day 28 (RR 1.28, 95% CI 1.05-1.57). The rate of virologic conversion was not significantly different between the two groups. Conclusion: The study concludes that remdesivir is safe and effective in the treatment of moderate-to-critical COVID-19 in a real-world setting in Indonesia.

A K+-sensitive photonic crystal hydrogel sensor for efficient visual monitoring of hyperkalemia/hypokalemia

Potassium ions (K⁺) play crucial roles in many biological processes. Abnormal K⁺ levels in the body are usually associated with physiological disorders or diseases, and thus, developing K⁺-sensitive sensors/devices is of great importance for disease diagnosis and health monitoring. Herein, we report a K⁺-sensitive photonic crystal hydrogel (PCH) sensor with bright structural colors for efficient monitoring of serum potassium. This PCH sensor consists of a poly(acrylamide-co-N-isopropylacrylamide-co-benzo-15-crown-5-acrylamide) (PANBC) smart hydrogel with embedded Fe₃O₄ colloidal photonic crystals (CPCs), which could strongly diffract visible light and endow the hydrogel with brilliant structural colors. The rich 15-crown-5 (15C5) units appended on the polymer backbone could selectively bind K⁺ ions to form stable 2 : 1 [15C5]₂/K⁺ supramolecular complexes. These bis-bidentate complexes served as physical crosslinkers to crosslink the hydrogel and contracted its volume, and thus reduced the lattice spacing of Fe₃O₄ CPCs and blue-shifted the light diffraction, and finally reported on the K⁺ concentrations by a color change of the PCH. Our fabricated PCH sensor possessed high K⁺ selectivity and pH- and thermo-sensitive response performances to K⁺. Most interestingly, the K⁺-responding PANBC PCH sensor could be conveniently regenerated via simple alternate flushing with hot/cold water due to the excellent thermosensitivity of the introduced PNIPAM moieties into the hydrogel. Such a PCH sensor provides a simple, low-cost and efficient strategy for visualized monitoring of hyperkalemia/hypokalemia, which will significantly promote the development of biosensors.

Development and external validation of a prognostic tool for nonsevere COVID-19 inpatients

To develop a machine learning model and nomogram to predict the probability of persistent virus shedding (PVS) in hospitalized patients with coronavirus disease 2019 (COVID-19), the clinical symptoms and signs, laboratory parameters, cytokines, and immune cell data of 429 patients with nonsevere COVID-19 were retrospectively reviewed. Two models were developed using the Akaike information criterion (AIC). The performance of these two models was analyzed and compared by the receiver operating characteristic (ROC) curve, calibration curve, net reclassification index (NRI), and integrated discrimination improvement (IDI). The final model included the following independent predictors of PVS: sex, C-reactive protein (CRP) level, interleukin-6 (IL-6) level, the neutrophil-lymphocyte ratio (NLR), monocyte count (MC), albumin (ALB) level, and serum potassium level. The model performed well in both the internal validation (corrected C-statistic = 0.748, corrected Brier score = 0.201) and external validation datasets (corrected C-statistic = 0.793, corrected Brier score = 0.190). The internal calibration was very good (corrected slope = 0.910). The model developed in this study showed high discriminant performance in predicting PVS in nonsevere COVID-19 patients. Because of the availability and accessibility of the model, the nomogram designed in this study could provide a useful prognostic tool for clinicians and medical decision-makers.

Importance of Magnesium Status in COVID-19

A large amount of published research points to the interesting concept (hypothesis) that magnesium (Mg) status may have relevance for the outcome of COVID-19 and that Mg could be protective during the COVID disease course. As an essential element, Mg plays basic biochemical, cellular, and physiological roles required for cardiovascular, immunological, respiratory, and neurological functions. Both low serum and dietary Mg have been associated with the severity of COVID-19 outcomes, including mortality; both are also associated with COVID-19 risk factors such as older age, obesity, type 2 diabetes, kidney disease, cardiovascular disease, hypertension, and asthma. In addition, populations with high rates of COVID-19 mortality and hospitalization tend to consume diets high in modern processed foods, which are generally low in Mg. In this review, we review the research to describe and consider the possible impact of Mg and Mg status on COVID-19 showing that (1) serum Mg between 2.19 and 2.26 mg/dL and dietary Mg intakes > 329 mg/day could be protective during the disease course and (2) inhaled Mg may improve oxygenation of hypoxic COVID-19 patients. In spite of such promise, oral Mg for COVID-19 has thus far been studied only in combination with other nutrients. Mg deficiency is involved in the occurrence and aggravation of neuropsychiatric complications of COVID-19, including memory loss, cognition, loss of taste and smell, ataxia, confusion, dizziness, and headache. Potential of zinc and/or Mg as useful for increasing drug therapy effectiveness or reducing adverse effect of anti-COVID-19 drugs is reviewed. Oral Mg trials of patients with COVID-19 are warranted.

Mechanistic-Based Classification of Endocytosis-Related Inhibitors: Does It Aid in Assigning Drugs against SARS-CoV-2?

Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) canonically utilizes clathrin-mediated endocytosis (CME) and several other endocytic mechanisms to invade airway epithelial cells. Endocytic inhibitors, particularly those targeting CME-related proteins, have been identified as promising antiviral drugs. Currently, these inhibitors are ambiguously classified as chemical, pharmaceutical, or natural inhibitors. However, their varying mechanisms may suggest a more realistic classification system. Herein, we present a new mechanistic-based classification of endocytosis inhibitors, in which they are segregated among four distinct classes including: (i) inhibitors that disrupt endocytosis-related protein-protein interactions, and assembly or dissociation of complexes; (ii) inhibitors of large dynamin GTPase and/or kinase/phosphatase activities associated with endocytosis; (iii) inhibitors that modulate the structure of subcellular components, especially the plasma membrane, and actin; and (iv) inhibitors that cause physiological or metabolic alterations in the endocytosis niche. Excluding antiviral drugs designed to halt SARS-CoV-2 replication, other drugs, either FDA-approved or suggested through basic research, could be systematically assigned to one of these classes. We observed that many anti-SARS-CoV-2 drugs could be included either in class III or IV as they interfere with the structural or physiological integrity of subcellular components, respectively. This perspective may contribute to our understanding of the relative efficacy of endocytosis-related inhibitors and support the optimization of their individual or combined antiviral potential against SARS-CoV-2. However, their selectivity, combined effects, and possible interactions with non-endocytic cellular targets need more clarification.

Low dietary sodium potentially mediates COVID-19 prevention associated with whole-food plant-based diets

Compared with an omnivorous Western diet, plant-based diets containing mostly fruits, vegetables, grains, legumes, nuts and seeds, with restricted amounts of foods of animal origin, are associated with reduced risk and severity of COVID-19. Additionally, inflammatory immune responses and severe acute respiratory symptoms of COVID-19, including pulmonary oedema, shortness of breath, fever and nasopharyngeal infections, are associated with Na toxicity from excessive dietary Na. High dietary Na is also associated with increased risks of diseases and conditions that are co-morbid with COVID-19, including chronic kidney disease, hypertension, stroke, diabetes and obesity. This article presents evidence that low dietary Na potentially mediates the association of plant-based diets with COVID-19 prevention. Processed meats and poultry injected with sodium chloride contribute considerable amounts of dietary Na in the Western diet, and the avoidance or reduction of these and other processed foods in whole-food plant-based (WFPB) diets could help lower overall dietary Na intake. Moreover, high amounts of K in plant-based diets increase urinary Na excretion, and preagricultural diets high in plant-based foods were estimated to contain much lower ratios of dietary Na to K compared with modern diets. Further research should investigate low Na in WFPB diets for protection against COVID-19 and co-morbid conditions.

Nutritional deficiencies that may predispose to long COVID

Multiple nutritional deficiencies (MND) confound studies designed to assess the role of a single nutrient in contributing to the initiation and progression of disease states. Despite the perception of many healthcare practitioners, up to 25% of Americans are deficient in five-or-more essential nutrients. Stress associated with the COVID-19 pandemic further increases the prevalence of deficiency states. Viral infections compete for crucial nutrients with immune cells. Viral replication and proliferation of immunocompetent cells critical to the host response require these essential nutrients, including zinc. Clinical studies have linked levels of more than 22 different dietary components to the likelihood of COVID-19 infection and the severity of the disease. People at higher risk of infection due to MND are also more likely to have long-term sequelae, known as Long COVID.

The association between acid-base status and clinical outcome in critically ill COVID-19 patients admitted to intensive care unit with an emphasis on high anion gap metabolic acidosis

OBJECTIVE

The aim of this study was to identify arterial blood gas (ABG) abnormalities, with a focus on a high anion gap (AG) metabolic acidosis and evaluate outcomes in coronavirus disease 2019 (COVID-19) patients admitted to the ICU.

METHODS

A retrospective, observational study was conducted in a tertiary hospital in Cape Town during the first and second COVID-19 waves. Age, gender, sodium (Na), potassium (K), chloride (Cl), bicarbonate (HCO₃std), pH, partial pressure of carbon dioxide (pCO₂), creatinine, estimated glomerular filtration rate (eGFR), lactate levels and ABG results were obtained. The Pearson χ2 test or Fisher exact test and the Wilcoxon rank-sum test were used to compare mortality and survival. To identify factors associated with non-survival, a multivariable model was developed.

RESULTS

This study included 465 patients, 226 (48%) of whom were female. The sample population's median (IQR) age was 54.2 (46.1-61.3) years, and 63% of the patients died. ABG analyses found that 283 (61%) of the 465 patients had alkalosis (pH ≥ 7.45), 65 (14%) had acidosis (pH ≤ 7.35) and 117 (25%) had normal pH (7.35-7.45). In the group with alkalosis, 199 (70.3%) had a metabolic alkalosis and in the group with acidosis, 42 (64%) had a metabolic acidosis with an increased AG of more than 17. Non-survivors were older than survivors (56.4 years versus 50.3 years, p < .001).

CONCLUSION

Most of the COVID-19 patients admitted to the ICU had an alkalosis, and those with acidosis had a much worse prognosis. Higher AG metabolic acidosis was not associated with patients' characteristics.

Electrolyte imbalances as poor prognostic markers in COVID-19: a systemic review and meta-analysis

PURPOSE

Serum electrolyte imbalances are highly prevalent in COVID-19 patients. However, their associations with COVID-19 outcomes are inconsistent, and of unknown prognostic value. We aim to systematically clarify the associations and prognostic accuracy of electrolyte imbalances (sodium, calcium, potassium, magnesium, chloride and phosphate) in predicting poor COVID-19 clinical outcome.

METHODS

PubMed, Embase and Cochrane Library were searched. Odds of poor clinical outcome (a composite of mortality, intensive-care unit (ICU) admission, need for respiratory support and acute respiratory distress syndrome) were pooled using mixed-effects models. The associated prognostic sensitivity, positive and negative likelihood ratios (LR + , LR-) and predictive values (PPV, NPV; assuming 25% pre-test probability), and area under the curve (AUC) were computed.

RESULTS

We included 28 observational studies from 953 records with low to moderate risk-of-bias. Hyponatremia (OR = 2.08, 95% CI = 1.48-2.94, I² = 93%, N = 8), hypernatremia (OR = 4.32, 95% CI = 3.17-5.88, I² = 45%, N = 7) and hypocalcemia (OR = 3.31, 95% CI = 2.24-4.88, I² = 25%, N = 6) were associated with poor COVID-19 outcome. These associations remained significant on adjustment for covariates such as demographics and comorbidities. Hypernatremia was 97% specific in predicting poor outcome (LR + 4.0, PPV = 55%, AUC = 0.80) despite no differences in CRP and IL-6 levels between hypernatremic and normonatremic patients. Hypocalcemia was 76% sensitive in predicting poor outcome (LR- 0.44, NPV = 87%, AUC = 0.71). Overall quality of evidence ranged from very low to moderate.

CONCLUSION

Hyponatremia, hypernatremia and hypocalcemia are associated with poor COVID-19 clinical outcome. Hypernatremia is 97% specific for a poor outcome, and the association is independent of inflammatory marker levels. Further studies should evaluate if correcting these imbalances help improve clinical outcome.

Electrolyte Imbalance Among Bangladeshi Patients With COVID-19

Introduction Infection with SARS-CoV-2 begins in the lower respiratory tract, but COVID-19 often involves the renal system, resulting in serum electrolyte imbalance. Monitoring serum electrolyte levels and parameters of liver and kidney function is essential to understand disease prognosis. Objectives This study aimed to determine the effect of imbalances in serum electrolytes and other parameters on COVID-19 severity. Material and method This retrospective study comprised 241 patients, ages 14 years and older, including 186 patients who were moderately affected and 55 who were categorized as severely affected by COVID-19. Serum electrolytes (sodium (Na⁺), potassium (K⁺), and chloride (Cl^-)) and biomarkers of kidney and liver function (creatinine and alanine aminotransferase (ALT)) were measured and correlated with disease severity. This research was conducted among admitted patients of Holy Family Red Crescent Medical College Hospital designated into two groups based on retrospective hospital records. Individuals with moderate illness had evidence of lower respiratory tract infection (cough, cold, breathless, etc.) during clinical assessment or imaging (chest X-ray and computed tomography (CT) scan of the lungs) and have an oxygen saturation by pulse oximetry (SpO₂) ≥ 94% on room air at sea level. The severely ill group involved individuals with SpO₂ ≤94% on room air at sea level and respiratory rate ≥ 30 breaths/minute, and critically ill patients are those who needed mechanical ventilation or required intensive care unit (ICU) care. This categorization was based on the Coronavirus Disease 2019 (COVID-19) Treatment Guidelines (https://www.covid19treatmentguidelines.nih.gov/about-the-guidelines/whats-new/). Results Average Na⁺ and creatinine increased by 2.30 parts (95% confidence interval (CI) = 0.20, 4.81, P = 0.041) and 0.35 units (95% CI = 0.03, 0.68, P = 0.043) in severe cases compared with moderate cases. Older participants had relatively Na⁺ lowered to -0.06 parts (95% CI = -0.12, -0.001, P = 0.045), significant Cl^- reduction by 0.09 units (95% CI = -0.14, -0.04, P = 0.001), and ALT by 0.47 units (95% CI = -0.88, -0.06, P = 0.024), whereas serum creatinine was increased by 0.01 parts (95% CI = 0.001, 0.02, P = 0.024). The creatinine and ALT of COVID-19 participants were significantly higher in males by 0.34 units and 23.2 units, respectively, compared with females. In severe COVID-19 cases compared with moderate cases, the risks of hypernatremia, elevated chloride levels, and elevated serum creatinine levels were increased by 2.83-fold (95% CI = 1.26, 6.36, P = 0.012), 5.37-fold (95% CI = 1.90, 15.3, P = 0.002), and 2.00-fold (95% CI = 1.08, 4.31, P = 0.039), respectively. Conclusion Serum electrolyte and biomarker levels can serve as good indicators of the condition and disease prognosis of patients with COVID-19. Our purpose in this study was to determine the association between serum electrolyte imbalance and disease severity. We collected data from ex post facto hospital records and did not intend to assess the mortality rate. Consequently, this study expects that the prompt diagnosis of electrolyte disparity or disturbance possibly minimizes COVID-19-related morbidity and mortality.

Baseline electrolyte disorders predict disease severity and mortality in patients with COVID-19

Distinguishing critical laboratory biomarkers for disease severity at the time of hospital presentation is important for early identification of patients who are most likely to have poor outcomes and effective use of health resources. This study aimed to evaluate whether electrolyte imbalances on hospital admission predict severe disease and mortality in patients with coronavirus disease 2019 (COVID-19). We retrospectively collected data on the blood electrolyte concentrations of 286 COVID-19 patients at admission. The correlations between electrolyte imbalances, inflammation, and thrombosis markers in COVID-19 patients were also evaluated. We assessed the predictive performance of baseline blood electrolyte concentrations for severe disease and death using receiver operating characteristic curve analysis and multivariate logistic regression methods. Abnormalities in serum sodium, calcium, and potassium levels at admission were found at 20.6%, 14%, and 4.2%, respectively in this study. In the receiver operating characteristic curve analyses, hypocalcemia and hyponatremia effectively predicted disease progression to hospitalization (area under the curve 0.82, P < .001 and 0.81, P < .001, respectively) and 30-day mortality (area under the curve 0.85, P < .001 and 0.91, P < .001, respectively). In the multivariate logistic regression analysis, baseline hypocalcemia was identified as an independent risk factor associated with the risk of hospitalization (β = 2.019, P = .01; odds ratio: 7.53). Baseline hypocalcemia and hyponatremia effectively predicted disease progression toward hospitalization and 30-day mortality in patients with COVID-19. Clinicians should closely follow up or reevaluate COVID-19 patients with baseline electrolyte disorders.

Cardio-cerebrovascular complications in COVID-19 patients: A retrospective cohort study

Background

Recent studies have highlighted the cardio-cerebrovascular manifestations of coronavirus disease 2019 (COVID-19).

Objective

This study aimed to analyze the likelihood of cardiovascular and cerebrovascular manifestations among patients with COVID-19-positive individuals in South Korea.

Methods

A cohort database for COVID-19 from the National Health Insurance Service was used which included patients diagnosed with COVID-19 between January 1 and June 4, 2020. Individuals who tested COVID-19 positive, notwithstanding the severity of the disease, were designated as cases. COVID-19- negative individuals were used as controls for the study. The exclusion criteria included people who had a history of cardiovascular and cerebrovascular diseases between 2015 and 2019. A new diagnosis of cardiovascular and cerebrovascular complications was considered the primary endpoint. The adjusted incidence rate ratio (IRR) of development of complications was estimated using log-link Poisson regression. The model was adjusted at two levels, the first one included age and sex while the second included age, sex, residence area, and level of income. The hazard ratio (HR) was estimated using Cox-proportional hazard regression analysis while adjusting for all demographic variables and covariates.

Results

Significant results were obtained for acute conditions, such as ischemic heart disease and cerebral hemorrhage. The IRR of COVID-19- positive individuals compared with that of controls for the diagnosis of ischemic heart disease was 1.78 (1.57-2.02; 95% confidence interval [CI]) when adjusted for age and sex. HR was calculated as 3.02 (2.19-4.17; 95% CI) after adjusting for the covariates. In case of cerebral hemorrhage, the adjusted IRR was 2.06 (1.25-3.40; 95% CI) and the adjusted HR was 4.08 (0.90-19.19; 95% CI).

Conclusion

The findings of our study suggest that COVID-19 infection can be a significant risk factor for acute cardiovascular complications, such as ischemic heart disease and acute cerebrovascular complications, such as cerebral infarction, after properly adjusting for covariates.

A prediction model for the efficacy of continuous positive airway pressure on bronchiolitis

Objectives

Prediction of the efficacy of continuous positive airway pressure (CPAP) on bronchiolitis is necessary for timely treatment. This study aims to establish a nomogram for efficacy of CPAP on bronchiolitis, and compares accuracy with Pediatric Risk of Mortality III (PRISM III), Brighton Pediatric Early Warning Score (Brighton PEWS) and Pediatric Critical Illness Score (PCIS).

Methods

From February 2014 to December 2020, data on children diagnosed with bronchiolitis and treated with CPAP in Chongqing was collected. The nomogram was evaluated by using multivariate logistic regression analysis. We compared the predictive value of model with PRISM III, PEWS and PCIS.

Results

A total of 510 children were included. The nomogram prediction model including fever, APTT, white blood cells, serum potassium concentration, lactic acid, immunodeficiency, atelectasis, lung consolidation, congenital airway dysplasia and congenital heart disease was established. The AUC of the nomogram was 0.919 in the training set and 0.947 in the validating set. The model fitted well, as evidenced by the calibration curve and Hosmer-Lemeshow goodness-of-fit test. We discovered that the nomogram significantly performed better than PRISM III, PCIS and PEWS.

Conclusions

A nomogram including ten factors for predicting the efficacy of CPAP on bronchiolitis was established. It had higher performance than the PRISM III, PCIS, and PEWS in terms of clinical benefits.

Role of Micronutrients and Gut Microbiota-Derived Metabolites in COVID-19 Recovery

A balanced and varied diet provides diverse beneficial effects on health, such as adequate micronutrient availability and a gut microbiome in homeostasis. Besides their participation in biochemical processes as cofactors and coenzymes, vitamins and minerals have an immunoregulatory function; meanwhile, gut microbiota and its metabolites coordinate directly and indirectly the cell response through the interaction with the host receptors. Malnourishment is a crucial risk factor for several pathologies, and its involvement during the Coronavirus Disease 2019 pandemic has been reported. This pandemic has caused a significant decline in the worldwide population, especially those with chronic diseases, reduced physical activity, and elder age. Diet and gut microbiota composition are probable causes for this susceptibility, and its supplementation can play a role in reestablishing microbial homeostasis and improving immunity response against Coronavirus Disease 2019 infection and recovery. This study reviews the role of micronutrients and microbiomes in the risk of infection, the severity of disease, and the Coronavirus Disease 2019 sequelae.

Acute kidney injury and electrolyte disorders in COVID-19

Acute kidney injury (AKI) and electrolyte disorders are important complications of hospitalized coronavirus disease 2019 (COVID-19) patients. AKI is thought to occur due to multiple pathophysiological mechanisms, such as multiple organ dysfunction (mainly cardiac and respiratory), direct viral entry in the renal tubules, and cytokine release syndrome. AKI is present in approximately one in every ten hospitalized COVID-19 patients. The incidence rates of AKI increase in patients who are admitted to the intensive care unit (ICU), with levels higher than 50%. Additionally, renal replacement therapy (RRT) is used in 7% of all AKI cases, but in nearly 20% of patients admitted to an ICU. COVID-19 patients with AKI are considered moderate-to-severe cases and are managed with multiple interdisciplinary conducts. AKI acts as a risk factor for mortality in severe acute respiratory syndrome coronavirus 2 infection, especially when RRT is needed. Electrolyte disorders are also common manifestations in hospitalized COVID-19 patients, mainly hyponatremia, hypokalemia, and hypocalcemia. Hyponatremia occurs due to a combination of syndrome of inappropriate secretion of antidiuretic hormone and gastrointestinal fluid loss from vomiting and diarrhea. When it comes to hypokalemia, its mechanism is not fully understood but may derive from hyperaldosteronism due to renin angiotensin aldosterone system overstimulation and gastrointestinal fluid loss as well. The clinical features of hypokalemia in COVID-19 are similar to those in other conditions. Hypocalcemia is the most common electrolyte disorder in COVID-19 and seems to occur because of vitamin D deficiency and parathyroid imbalance. It is also highly associated with longer hospital and ICU stay.

Molecular mechanisms and therapeutic effects of different vitamins and minerals in COVID-19 patients

COVID-19 is a rapidly spreading disease, which has caught the world by surprise. Millions of people suffer from illness, and the mortality rates are dramatically high. Currently, there is no specific and immediate treatment for this disease. Remedies are limited to supportive regiments and few antiviral and anti-inflammatory drugs. The lack of a definite cure for COVID-19 is the reason behind its high mortality and global prevalence. COVID-19 can lead to a critical illness with severe respiratory distress and cytokine release. Increased oxidative stress and excessive production of inflammatory cytokines are vital components of severe COVID-19. Micronutrients, metalloids, and vitamins such as iron, manganese, selenium, Zinc, Copper, vitamin A, B family, and C are among the essential and trace elements that play a pivotal role in human nutrition and health. They participate in metabolic processes that lead to energy production. In addition, they support immune functions and act as antioxidants. Therefore, maintaining an optimal level of micronutrients intake, particularly those with antioxidant activities, is essential to fight against oxidative stress, modulate inflammation, and boost the immune system. Therefore, these factors could play a crucial role in COVID-19 prevention and treatment. In this review, we aimed to summarize antiviral properties of different vitamins and minerals. Moreover, we will investigate the correlation between them and their effects in COVID-19 patients.

Clinical nutrition approach in medical management of COVID-19 hospitalized patients: A narrative review

BACKGROUND

Malnutrition in COVID-19 hospitalized patients is associated with a high-risk condition to increase disease severity and prolonging the recovery period. Therefore, nutritional therapy, including supplements plays a critical role to reduce disease-related complications and the length of hospital stay.

AIM

To review the latest evidence on nutritional management options in COVID-19 hospitalized patients, as well as possibly prescribed supplements. Methods: This review was conducted by considering the latest recommendations, using the guidelines of the American Society of Enteral and Parenteral (ASPEN) and the European Society of Enteral and Parenteral (ESPEN), and searching Web of Science, PubMed/Medline, ISI, and Medline databases. The relevant articles were found using a mix of related mesh terms and keywords. We attempted to cover all elements of COVID-19 hospitalized patients' dietary management. Results: Energy demand in COVID-19 patients is a vital issue. Indirect Calorimetry (IC) is the recommended method to measure resting energy expenditure. However, in the absence of IC, predictive equations may be used. The ratio of administered diet for the macronutrients could be based on the phase and severity of Covid-19 disease. Moreover, there are recommendations for taking micronutrient supplements with known effects on improving the immune system or reducing inflammation. Conclusions: Nutritional treatment of COVID-19 patients in hospitals seems to be an important element of their medical care. Enteral nutrition would be the recommended feeding method for early nutrition support. However, data in the COVID-19 nutritional domain relating to micronutrient supplementation are still fragmentary and disputed, and further study is required.

The role of electrolyte imbalances in predicting the severity of COVID-19 in the hospitalized patients: a cross-sectional study

Coronavirus disease 2019 (COVID-19) can be fatal in severe cases. Accordingly, predicting the severity and prognosis of the disease is valuable. This study examined the role of electrolyte imbalances in predicting the severity of COVID-19. In this cross-sectional study, 169 hospitalized patients with COVID-19 were included and categorized into three groups based on the severity of the disease (moderate, severe, and critical). Serum levels of electrolytes (calcium [Ca], phosphorus [P], sodium [Na], potassium [k], and magnesium [Mg]), inflammatory markers (D-dimer, C-reactive protein [CRP], ferritin, and lactate dehydrogenase [LDH]), and 25OHVitamin D were measured. The mean age of patients was 53 years, and 54% were male. They had moderate, severe, and critical illnesses in 22%, 47%, and 31%, respectively. CRP, D-dimer, and ferritin increased with the severity of the disease. The lower median values of Mg, Na, 25OHVitamin D, Ca, LDH, and higher median lymphocyte counts were observed in the moderate vs. the severe group (P < 0.05). These parameters have acceptable sensitivity and specificity at the suggested cut-off level to discriminate the moderate and critical cases. Serum parameters introduced in this study are appropriate for differentiating between critical and moderate cases. The electrolyte imbalance can predict critical patients.

The Mutual Relationship among Cardiovascular Diseases and COVID-19: Focus on Micronutrients Imbalance

Micronutrients are ions and vitamins humbly required by the human body. They play a main role in several physiological mechanisms and their imbalance is strongly associated with potentially-fatal complications. Micronutrient imbalance is associated with many cardiovascular diseases, such as arrythmias, heart failure, and ischemic heart disease. It has been also observed in coronavirus disease 2019 (COVID-19), particularly in most severe patients. The relationship between cardiovascular diseases and COVID-19 is mutual: the latter triggers cardiovascular disease onset and worsening while patients with previous cardiovascular disease may develop a more severe form of COVID-19. In addition to the well-known pathophysiological mechanisms binding COVID-19 and cardiovascular diseases together, increasing importance is being given to the impact of micronutrient alterations, often present during COVID-19 and able to affect the balance responsible for a good functioning of the cardiovascular system. In particular, hypokalemia, hypomagnesemia, hyponatremia, and hypocalcemia are strongly associated with worse outcome, while vitamin A and D deficiency are associated with thromboembolic events in COVID-19. Thus, considering how frequent the cardiovascular involvement is in patients with COVID-19, and how it majorly affects their prognosis, this manuscript provides a comprehensive review on the role of micronutrient imbalance in the interconnection between COVID-19 and cardiovascular diseases.

Laboratory Findings in Different Disease Status of COVID-19 Admitted Patients at Dilla University Referral Hospital Treatment Center, South Ethiopia

Background

Millions were infected and many were dying because of the coronavirus disease 2019, since its emergence. The patients experience asymptomatic, mild, moderate, severe and critical disease with varying signs and symptoms. Decreased lymphocytes and abnormal liver and renal function tests are common among COVID-19 patients. Severe and critical cases show higher number of white blood cells, and neutrophils. However, studies showed different laboratory findings in different disease status. Therefore, this study investigated laboratory findings of COVID-19 admitted patients at Dilla University Referral Hospital treatment center, South Ethiopia.

Methods

A retrospective study design was conducted on 220 patients confirmed by real time polymerase chain reaction, and admitted to Dilla University Referral Hospital treatment center from September 2020 to July 2021. Data were collected from the patients’ record, and analyzed by GraphPad Prism version 8.0.1.244 software. Descriptive statistics were used to analyze the frequency while independent t-test was used to compare means of each parameter for each disease status.

Results

Of the 220 study cases, 120 (54.5%) were severe, 89 (40.5%) were moderate and 11 (5.0%) were mild. One hundred forty (71.1%) of the 197 laboratory tested cases, 87 (77.7%) of severe, and 49 (64.5%) of the moderate cases had neutrophils above normal range. However, 134 (68.0%) of them, 82 (73.2%) of severe and 49 (64.5%) of moderate cases showed decreased lymphocyte level. Most of the cases showed an increased level of aspartate transaminase, alanine transaminase, alkaline phosphatase, total bilirubin, and total calcium. There was statistically significant mean neutrophils (p=0.04), number of white blood cells (p= 0.02), and creatinine level (p=0.00) difference between severe and mild cases.

Conclusion

Most of the severe COVID-19 patients showed increased neutrophils, liver function tests; and decreased lymphocytes; suggesting higher inflammation and lymphopenia. Therefore, patients with severe and critical disease status require close follow-up.

Linear mixed model analysis to evaluate correlations between remdesivir adverse effects with age and gender of patients with mild Covid-19 pneumonia

We aimed to assess longitudinal changes in clinical indexes of corona disease 2019 (Covid-19) patients with mild pulmonary infection during 5 days of remdesivir therapy and determine the effect of age and gender on remdesivir adverse effects (AE). Patients' clinical data including inflammatory markers, liver and renal function tests, and heart rate (HR) were extracted from medical records. Linear mixed model (LMM) was used to analyze longitudinal changes in patients' clinical indexes. Gender and age were inserted in LMM as covariates to find their correlation with AE and clinical indexes. Of 84 patients, 35 patients met our criteria for the study. There were significant increases in mean levels of white blood cell (WBC; p = 0.005), alanine aminotransferase (ALT; p = 0.001), aspartate aminotransferase (p = 0.001), blood urea nitrogen (BUN; p = 0.001), and creatinine (p = 0.006), whereas mean levels of erythrocyte sedimentation rate (p = 0.005), C-reactive protein (p = 0.001), alkaline phosphatase (p = 0.001), and potassium (p = 0.003) decreased significantly. Estimated glomerular filtration rate (p = 0.001) and HR (p = 0.001) showed a notable decline over the course of treatment. LMM analysis showed that mean changes in WBC (β = 0.94, p = 0.029), creatinine (β = 0.12, p = 0.020), and HR (β = 6.47, p = 0.008) were greater in males than in females. Also, age of patients had a significant effect on the mean changes of WBC (β = -0.02, p = 0.023), sodium (β = -0.06, p = 0.010), BUN (β = 0.23, p = 0.001), and HR (β = -0.29, p = 0.001). Despite no renal and liver dysfunction, Covid-19 patients with mild pulmonary infection may develop some remdesivir AE and attributed side effects might be affected by gender and age of patients.

Biochemical and Anthropometric Nutritional Assessment in Children Infected with COVID-19: A Cross-sectional Study

Background: Severe acute respiratory syndrome has led to a pandemic of coronavirus disease 2019 (COVID-19). Malnutrition either biochemically or anthropometrically is a well-known risk factor for COVID-19 and may be the vice versa Objectives  : To investigate the prevalence of malnutrition in children infected with COVID-19 through evaluating the nutritional biomarkers such as serum electrolytes, serum albumin and hemoglobin together with the anthropometric assessment.  Methods: A cross sectional study that was conducted at ElMatria Teaching Hospital for all children admitted with confirmed COVID-19 over a period of 6 months from 1st February 2021 to the end of July, 2021. Nutritional biochemical evaluation included serum electrolytes particularly   the potassium and other nutritional biomarkers such  as serum albumin and hemoglobin. Nutritional anthropometric evaluation depended on BMI (body mass index), the height/length, weight for length and weight for height..The prevalence of malnutrition esp. hypokalemia was the main outcome. Results: Hypokalemia was present in 21.8% of the study participants . Other nutritional biomarkers were found  as hyponatremia, hypocalcemia , hypophosphatemia, hypomagnesemia were detected in 49.1% , 38.2%,21.8% and 34.5%  of the study subjects respectively. Anthropometric malnutrition was present in most of the enrolled children with COVID-19 in the study (65.5 %  (n= 36) )through which overweight and obese children occupied a greater percentage. Conclusion: Malnutrition either biochemically or anthropometrically could be linked to   COVID-19 in children. COVID-19 could have negative outcomes on the nutritional status such as electrolytes disturbances. Both malnutrition and COVID-19 are considered synergistic associations   Keywords: Malnutrition. COVID-19. Children. Hypokalemia. Obesity

Assessment of hypokalemia and clinical prognosis in Patients with COVID-19 in Yangzhou, China

Background

Hypokalemia is a frequent electrolyte imbalance in patients with COVID-19. The aim of this study was to estimate the association between hypokalemia and clinical prognosis in patients with moderate COVID-19.

Methods

A single-center, retrospective, observational study was conducted on 81 non-ICU admitted patients with moderate COVID-19 according to the criteria issued by the Chinese Health Bureau in the Third People’s Hospital of Yangzhou (Northern Jiangsu People’s Hospital New District Branch) from 4th to 25th August 2021. The demographic, clinical, and laboratory data were reviewed and collected, then the correlation between hypokalemia and prognosis was determined.

Results

The level of serum potassium of patients ranged from 2.80 mmol/L to 4.70 mmol/L. Hypokalemia was detected in 39 out of the 81 included patients (48.15%) during hospitalization. Patients with hypokalemia had prolonged days of negative nucleic acid conversion and hospital stay. Correlation analysis showed that the level of serum potassium was negatively correlated with days of negative nucleic acid conversion and length of hospital stay. Bivariate logistic regression analysis proved that hypokalemia was a risk factor for prolonged hospital stay in patients with moderate COVID-19.

Conclusion

Hypokalemia was prevalent in patients with moderate COVID-19 in Yangzhou, China. Hypokalemia was associated with the prolonged hospital stay in patients with moderate COVID-19.

Review of the Pathophysiologic and Clinical Aspects of Hypokalemia in Children and Young Adults: an Update

This article examines the regulatory function of the skeletal muscle, renal, and adrenergic systems in potassium homeostasis. The pathophysiologic bases of hypokalemia, systematic approach for an early diagnosis, and therapeutic strategy to avert life-threatening complications are highlighted. By promoting skeletal muscle uptake, intense physical exercise (post), severe trauma, and several toxins produce profound hypokalemia. Hypovolemia due to renal and extra-renal fluid losses and ineffective circulation activate secondary aldosteronism causing urinary potassium wasting. In addition to hypokalemic alkalosis, primary aldosteronism causes low-renin hypertension. Non-aldosterone mineralocorticoid activation leading to low-renin and low-aldosterone hypertension occurs in Liddle's syndrome and apparent mineralocorticoid excess. Although there is enzymatic inhibition of cortisol synthesis in congenital adrenal hyperplasia, precursors of aldosterone produce low-renin hypokalemic hypertension. In addition to the glucocorticoid effect, hypercortisolism activates mineralocorticoid receptors in Cushing's syndrome. Genetic mutations involving furosemide-sensitive Na+-K+-2Cl- co-transporters and thiazide-sensitive Na+-Cl- transporters result in (non-hypertensive) salt-wasting nephropathy. Proximal and distal renal tubular acidosis is associated with hypokalemia. Eating disorders causing hypokalemia include bulimia, laxative abuse, and diuretic misuse. Low urinary potassium (<15 mmol/day) and/or low urinary chloride (<20 mol/L) suggest a gastrointestinal pathology. Co-morbidity of hypokalemia with chronic pulmonary and cardiovascular diseases may increase the fatality rate.

Awaiting a cure for COVID-19: therapeutic approach in patients with different severity levels of COVID-19

COVID-19 is an unpredictable infectious disease caused by SARS-CoV-2. The development of effective anti-COVID-19 vaccines has enormously minimized the risk of severe illness in most immunocompetent patients. However, unvaccinated patients and non-responders to the COVID-19 vaccine are at risk of shortand long-term consequences. In these patients, the outcome of COVID-19 relies on an interplay of multiple factors including age, immunocompetence, comorbidities, inflammatory response triggered by the virus as well as the virulence of SARS-CoV-2 variants. Generally, COVID-19 is asymptomatic or mildly symptomatic in young people, but it may manifest with respiratory insufficiency requiring mechanical ventilation in certain susceptible groups of patients. Furthermore, severe SARS-CoV-2 infection induces multiorgan failure syndrome by affecting liver, kidney heart and nervous system. Since December 2019, multiple drugs have been tested to treat COVID-19, but only a few have been proven effective to mitigate the course of the disease that continues to cause death and comorbidity worldwide. Current treatment of COVID-19 patients is essentially based on the administration of supportive oxygen therapy and the use of specific drugs such as steroids, anticoagulants, antivirals, anti-SARS-CoV-2 antibodies and immunomodulators. However, the rapid spread of new variants and the release of new data coming from the numerous ongoing clinical trials have created the conditions for maintaining a continuous updating of the therapeutic management of COVID-19 patients. Furthermore, we believe that a well-established therapeutic strategy along with the continuum of medical care for all patients with COVID-19 is pivotal to improving disease outcomes and restoring healthcare care fragmentation caused by the pandemic. This narrative review, focusing on the therapeutic management of COVID-19 patients, aimed to provide an overview of current therapies for (i) asymptomatic or mildly/moderate symptomatic patients, (ii) hospitalized patients requiring low-flow oxygen, (iii) high-flow oxygen and (iv) mechanical ventilation.

Incidence and risk factors for hyperkalaemia in patients treated for COVID-19 with nafamostat mesylate

What is known and objective

Nafamostat mesylate (NM) is used clinically in combination with antiviral drugs to treat coronavirus disease (COVID‐19). One of the adverse events of NM is hyperkalaemia due to inhibition of the amiloride‐sensitive sodium channels (ENaC). The incidence and risk factors for hyperkalaemia due to NM have been studied in patients with pancreatitis but not in COVID‐19. COVID‐19 can be associated with hypokalaemia or hyperkalaemia, and SARS‐CoV‐2 is thought to inhibit ENaC. Therefore, frequency and risk factors for hyperkalaemia due to NM may differ between COVID‐19 and pancreatitis. Hyperkalaemia may worsen the respiratory condition of patients. The objective of this study was to determine the incidence and risk factors for hyperkalaemia in COVID‐19 patients treated with favipiravir, dexamethasone and NM.

Methods

This retrospective study reviewed the records of hospitalized COVID‐19 patients treated with favipiravir and dexamethasone, with or without NM, between March 2020 and January 2021. Multivariable logistic regression analysis was performed to identify the risk factors for hyperkalaemia.

Results and Discussion

Of 45 patients who received favipiravir and dexamethasone with NM for the treatment of COVID‐19, 21 (47%) experienced hyperkalaemia. The duration of NM administration was a significant predictor of hyperkalaemia (odds ratio: 1.55, 95% confidence interval: 1.04–2.31, p = 0.031). The receiver‐operating characteristic curve analysis determined that the cut‐off value for predicting the number of days until the onset of hyperkalaemia was 6 days and the area under the curve was 0.707.

What is new and conclusion

This study revealed that the incidence of hyperkalaemia is high in patients treated for COVID‐19 with NM, and that the duration of NM administration is a key risk factor. When NM is administered for the treatment of COVID‐19, it should be discontinued within 6 days to minimize the risk of hyperkalaemia.

The Association of New-Onset Acute Kidney Injury and Mortality in Critically Ill Patients With COVID-19 With Less Severe Clinical Conditions at Admission: A Moderation Analysis

Acute kidney injury (AKI), electrolyte, and acid–base disorders complicate the clinical course of critically ill patients with coronavirus-associated disease (COVID-19) and are associated with poor outcomes. It is not known whether the severity of clinical conditions at admission in the intensive care unit (ICU) changes the clinical significance of AKI and/or electrolyte or acid–base disorders developing during ICU stay. We conducted a retrospective study in critically ill patients with COVID-19 to evaluate whether the severity of clinical conditions at admission in the ICU affects the impact of AKI and of serum electrolytes or acid–base status on mortality. We carried out a 28-day retrospective follow-up study on 115 critically ill patients consecutively admitted to ICU for severe COVID-19 at a tertiary care university hospital and surviving longer than 24 h. We collected baseline demographic and clinical characteristics, and longitudinal data on kidney function, kidney replacement therapy, serum electrolytes, and acid–base status. We used Cox proportional hazards multiple regression models to test the interaction between the time-varying variates new-onset AKI or electrolyte or acid–base disorders and Sequential Organ Failure Assessment (SOFA) or Acute Physiology and Chronic Health Evaluation II (APACHE II) score at admission. After adjusting for age, sex, Charlson’s comorbidity index, and AKI present at ICU admission, new-onset AKI was significantly associated with 28-day mortality only in the patients in the lowest and middle SOFA score tertiles [lowest SOFA tertile, hazard ratio (HR) 4.27 (95% CI: 1.27–14.44; P = 0.019), middle SOFA tertile, HR 3.17 (95% CI: 1.11–9.04, P = 0.031), highest SOFA tertile, HR 0.77 (95% CI: 0.24–2.50; P = 0.66); P = 0.026 for interaction with SOFA as a continuous variable]. After stratifying for APACHE II tertile, results were similar [adjusted HR (aHR) in the lowest tertile 6.24 (95% CI: 1.85–21.03, P = 0.003)]. SOFA or APACHE II at admission did not affect the relationship of serum electrolytes and acid–base status with mortality, except for new-onset acidosis which was associated with increased mortality, with the HR of death increasing with SOFA or APACHE II score (P < 0.001 and P = 0.013, respectively). Thus, unlike in the most severe critically ill patients admitted to the ICU for COVID-19, in patients with the less severe conditions at admission the development of AKI during the stay is a strong indicator of increased hazard of death.

Risk Factors Associated With COVID-19 Symptoms and Potential Vertical Transmission During Pregnancy: A Retrospective Cohort Study

Objective

The COVID-19 pandemic is of special concern for pregnant women. A growing body of evidence suggests the virus can have a deleterious impact upon outcomes related to birth and newborn health. There is a paucity of published research demonstrating the factors that influence disease severity among those who are pregnant, while a growing body of evidence demonstrates that vertical transmission occurs. Our study investigated the impact of maternal characteristics upon COVID-19 outcomes, as well as whether disease severity impacted pregnancy outcomes.

Methods

We conducted a retrospective cohort study of pregnant women with COVID-19 who were admitted to two public hospitals in our state between April-August, 2020. Pregnancy outcomes and clinical, laboratory, and placental data were collected.

Results

Thirty-four pregnant women tested positive for SARS-CoV-2. Among them, 55% (19/34) were symptomatic. Of those who were symptomatic, 68% (13/19) presented with fever and cough. Those with symptoms had a statistically significant higher pregestational mean body mass index (BMI) compared with asymptomatic women (35.7±7.9 vs 26.7±6.9, P=0.004). Screening of biochemical records demonstrated that symptomatic women had lower potassium levels compared with those who were asymptomatic (median: 3.70 mEq/L vs 4.30 mEq/L, P=0.009). The lowest potassium level (3.0 mEq/L) and one of the highest BMIs (42.4 kg/m²) was observed in the only case of postpartum mortality among the symptomatic women. We did not observe any influence of maternal COVID-19 severity on placental histopathology/infant health or evidence of vertical transmission.

Conclusion

High pregestational BMI and lower potassium levels were associated with the presence of COVID-19 symptoms among pregnant women.

Metabolic and electrolyte abnormalities as risk factors in drug-induced long QT syndrome

Drug-induced long QT syndrome (diLQTS) is the phenomenon by which the administration of drugs causes prolongation of cardiac repolarisation and leads to an increased risk of the ventricular tachycardia known as torsades de pointes (TdP). In most cases of diLQTS, the primary molecular target is the human ether-à-go-go-related gene protein (hERG) potassium channel, which carries the rapid delayed rectifier current (IKr) in the heart. However, the proarrhythmic risk associated with drugs that block hERG can be modified in patients by a range of environmental- and disease-related factors, such as febrile temperatures, alterations in pH, dyselectrolytaemias such as hypokalaemia and hypomagnesemia and coadministration with other drugs. In this review, we will discuss the clinical occurrence of drug-induced LQTS in the context of these modifying factors as well as the mechanisms by which they contribute to altered hERG potency and proarrhythmic risk.

Influence of Nutritional Intakes in Japan and the United States on COVID-19 Infection

The U.S. and Japan are both democratic industrialized societies, but the numbers of COVID-19 cases and deaths per million people in the U.S. (including Japanese Americans) are 12.1-times and 17.4-times higher, respectively, than those in Japan. The aim of this study was to investigate the effects of diet on preventing COVID-19 infection. An analysis of dietary intake and the prevalence of obesity in the populations of both countries was performed, and their effects on COVID-19 infection were examined. Approximately 1.5-times more saturated fat and less eicosapentaenoic acid/docosahexaenoic acid are consumed in the U.S. than in Japan. Compared with food intakes in Japan (100%), those in the U.S. were as follows: beef 396%, sugar and sweeteners 235%, fish 44.3%, rice 11.5%, soybeans 0.5%, and tea 54.7%. The last four of these foods contain functional substances that prevent COVID-19. The prevalence of obesity is 7.4- and 10-times greater in the U.S. than in Japan for males and females, respectively. Mendelian randomization established a causal relationship between obesity and COVID-19 infection. Large differences in nutrient intakes and the prevalence of obesity, but not racial differences, may be partly responsible for differences in the incidence and mortality of COVID-19 between the U.S. and Japan.