Anthropometric analysis of body habitus and outcomes in critically ill COVID-19 patients

Unveiling the detrimental vicious cycle linking skeletal muscle and COVID-19: A systematic review and meta-analysis

OBJECTIVE

Skeletal muscle catabolism supports multiple organs and systems during severe trauma and infection, but its role in COVID-19 remains unclear. This study investigates the interactions between skeletal muscle and COVID-19.

METHODS

The PubMed, EMbase, and The Cochrane Library databases were systematically searched from January 2020 to August 2023 for cohort studies focusing on the impact of skeletal muscle on COVID-19 prevalence and outcomes, and longitudinal studies examining skeletal muscle changes caused by COVID-19. Skeletal muscle quantity (SMQN) and quality (SMQL) were assessed separately. The random-effect model was predominantly utilized for statistical analysis.

RESULTS

Seventy studies with moderate to high quality were included. Low SMQN/SMQL was associated with an increased risk of COVID-19 infection (OR = 1.62, p < 0.001). Both the low SMQN and SMQL predicted COVID-19-related mortality (OR = 1.53, p = 0.016; OR = 2.18, p = 0.001, respectively). Mortality risk decreased with increasing SMQN (OR = 0.979, p = 0.009) and SMQL (OR = 0.972, p = 0.034). Low SMQN and SMQL were also linked to the need for intensive care unit/mechanical ventilation, increased COVID-19 severity, and longer hospital stays. Significant skeletal muscle wasting, characterized by reduced volume and strength, was observed during COVID-19 infection and the pandemic.

CONCLUSIONS

This study reveals a detrimental vicious circle between skeletal muscle and COVID-19. Effective management of skeletal muscle could be beneficial for treating COVID-19 infections and addressing the broader pandemic. These findings have important implications for the management of future virus pandemics.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023395476.

Association of Calf Circumference with Clinical and Biochemical Markers in Older Adults with COVID-19 Admitted at Intensive Care Unit: A Retrospective Cross-Sectional Study

BACKGROUND

COVID-19 is an infectious disease characterized by a severe catabolic and inflammatory state, leading to loss of muscle mass. The assessment of muscle mass can be useful to identify nutritional risk and assist in early management, especially in older adults who have high nutritional risks. The aim of this study was to evaluate the association of calf circumference (CC) with clinical and biochemical markers and mortality in older adults with COVID-19 admitted to the intensive care unit (ICU).

METHODS

A retrospective cross-sectional study was conducted in a public hospital. CC was adjusted for body mass index (BMI), reducing 3, 7, or 12 cm for a BMI of 25-29.9, 30-39.9, and ≥40 kg/m2, respectively, and classified as reduced when <33 cm for women and <34 cm for men. Pearson's correlation between BMI and CC was performed to assess the association between variables. Regression analysis was adjusted for sex, age, and BMI variables. Cox regression was used to assess survival related to CC.

RESULTS

A total of 208 older adults diagnosed with COVID-19 admitted to ICU were included, of which 84% (n = 176) were classified as having reduced CC. These patients were older, with lower BMI, higher nutritional risk, malnourished, and higher concentration of urea and urea-creatinine ratio (UCR) compared with the group with normal CC. There was an association between edematous patients at nutritional risk and malnourished with reduced CC in the Cox regression, either adjusted or not for confounding.

CONCLUSIONS

CC was not associated with severity, biochemical markers, or mortality in older adults with COVID-19 admitted to the ICU, but it was associated with moderately malnourished patients assessed by subjective global assessment (SGA).

Abdominal adipose tissue distribution assessed by computed tomography and mortality in hospitalised patients with COVID-19: a retrospective longitudinal cohort study

BACKGROUND

Visceral adiposity has been associated with an increased risk of critical illness in COVID-19 patients. However, if it also associates to a poor survival is still not well established. The aim of the study was to assess the relationship between abdominal fat distribution and COVID-19 mortality.

METHODS

In this six-month longitudinal cohort study, abdominal visceral (VAT) and subcutaneous adipose tissues (SAT) were measured by computed tomography in a cohort of 174 patients admitted to the emergency department with a diagnosis of COVID-19, during the first wave of pandemic. The primary exposure and outcome measures were VAT and SAT at hospital admission, and death at 30 and 180 days, respectively.

RESULTS

Overall survival was not different according to VAT (p = 0.94), SAT (p = 0.32) and VAT/SAT ratio (p = 0.64). However, patients in the lowest SAT quartile (thickness ≤ 11.25 mm) had a significantly reduced survival compared to those with thicker SAT (77 vs. 94% at day 30; 74 vs. 91% at day 180, p = 0.01). Similarly, a thinner SAT was associated with lower survival in Intensive Care Unit (ICU) admitted patients, independently of sex or age (p = 0.02). The VAT/SAT ratio showed a non-linear increased risk of ICU admission, which plateaued out and tended for inversion at values greater than 1.9 (p = 0.001), although was not associated with increased mortality rate.

CONCLUSIONS

In our cohort, visceral adiposity did not increase mortality in patients with COVID-19, but low SAT may be associated with poor survival.

The identification of an optimal body size parameter to adjust skeletal muscle area on chest CT in COVID-19 patients

Objectives

The most efficient way to adjust skeletal muscle area (SMA) derived from chest CT to body size remains unclear. We hypothesized that vertebral body area (VBA) measurement would allow such efficient adjustment.

Methods

We conducted a retrospective observational study of chest CT imaging in a cohort of critically ill COVID-19 patients. We measured paravertebral SMA at T5 level and T5 vertebral body anteroposterior length, width, and area. We used linear regression and multivariable modelling to assess the association of VBA with SMA.

Results

In 48 COVID-19 patients in ICU, T5 VBA could be easily derived from simple width and anteroposterior length linear measurements. T5 VBA (measured manually or estimated from width and length) performed similarly to height (R2 of 0.22) as an adjustment variable for SMA, with R2 of 0.23 and 0.22, respectively. Gender had the strongest correlation with SMA (R2 = 0.28). Adding height or age to a model using gender and VBA did not improve correlation.

Conclusions

Gender and estimated VBA from simple linear measurements at T5 level on CT images can be utilized for adjustment of SMA without the need for height. Validation of these findings in larger cohorts of critically ill patients is now needed.

Association between fat-free mass and survival in critically ill patients with COVID-19: A prospective cohort study

BACKGROUND

Most critically ill patients with COVID-19 experience malnutrition and weight loss associated with negative clinical outcomes. Our primary aim was to assess body composition during acute and late phase of illness in these patients in relation to clinical outcome and secondary to tailored nutrition support.

METHODS

This prospective cohort study included adult critically ill patients with COVID-19. Body composition (fat-free mass [FFM] [exposure of interest], fat mass [FM], skeletal muscle mass [SMM], and phase angle [PA]) was determined with multifrequency bioelectrical impedance analyses in the acute and late phase. Nutrition support data were collected simultaneously. Clinical outcome was defined as intensive care unit (ICU) survival (primary outcome) and 30-90 days thereafter, duration of mechanical ventilation, and length of ICU stay and length of hospital stay (LOS). Nonparametric tests and regression analyses were performed.

RESULTS

We included 70 patients (73% male, median age 60 years). Upon admission, median BMI was 30 kg/m2 , 54% had obesity (BMI > 30 kg/m2 ). Median weight change during ICU stay was -3 kg: +3 kg FM and -6 kg FFM (-4 kg SMM). Body composition changed significantly (P < 0.001). Regarding clinical outcome, only low PA was associated with prolonged LOS (odds ratio = 0.83, 95% CI = 0.72-0.96; P = 0.015). Patients with optimal protein intake (>80%) during acute phase maintained significantly more FFM (2.7 kg, P = 0.047) in the late phase compared with patients who received <80%.

CONCLUSION

FFM decreased significantly during acute and late phase of illness, but we observed no association with ICU survival. Only low PA was associated with prolonged LOS. FFM wasting likely occurred because of disease severity and immobility.

Sarcopenia and Mortality in Critically Ill COVID-19 Patients

COVID-19 can manifest as either asymptomatic or progressing to a severe phase in some patients, which may require hospitalization. These patients may experience dyspnea and hypoxia, leading to the development of acute respiratory distress syndrome. Studies have reported an increased risk of severe sarcopenia in COVID-19 patients during and after recovery. This narrative review aimed to summarize and synthesize available studies on the association between sarcopenia and mortality in critically ill COVID-19 patients. A total of 22 studies conducted on hospitalized COVID-19 patients were included in this review. Of those, 17 studies reported a direct association, while 5 studies showed no association between sarcopenia and mortality in severe COVID-19 patients. It is important to maintain muscle quality and quantity in defense against COVID-19. The measurement of lean muscle mass should be included in the risk assessment of severely ill COVID-19 patients as part of the therapy plan.

Assessment of body composition in adults hospitalized with acute COVID-19: a scoping review

Introduction

Body composition (BC) assessment can supply accurate information for in-hospital nutritional evaluation. The aim of this study was to explore in the literature how the studies assessed BC, for what purpose, and investigate the role of BC findings in COVID-19 hospitalized patients' outcomes.

Methods

A scoping review was conducted according to the methodology available on the Joanna Briggs Institute website. We used the PCC acronym for the systematic search (population: adults with COVID-19, concept: assessment of BC, context: hospital setting) and performed it on PubMed, Scopus, and the Web of Science on 16 September 2022. Eligibility criteria consisted of the utilization of BC assessment tools in COVID-19 patients. Studies in which BC was solely measured with anthropometry (perimeters and skinfolds) were excluded. No language restriction was applied.

Results

Fifty-five studies were eligible for the review. Out of the 55 studies, 36 used computed tomography (CT), 13 used bioelectrical impedance (BIA), and 6 used ultrasound (US). No studies with D3-creatinine, 24  h urine excretion, dual-energy X-ray absorptiometry, or magnetic resonance were retrieved. BC was mainly assessed to test associations with adverse outcomes such as disease severity and mortality.

Discussion

Studies assessing BC in hospitalized patients with COVID-19 used mainly CT and BIA and associated the parameters with severity and mortality. There is little evidence of BC being assessed by other methods, as well as studies on BC changes during hospitalization.

Association between visceral fat and influenza infection in Japanese adults: A population-based cross-sectional study

Background

Several studies have reported that obesity is associated with influenza infection; however, the role of visceral fat remains unclear. The aim of this study was to investigate the association between visceral fat and influenza infection in community-dwelling Japanese adults.

Methods

A cross-sectional study was performed using data from an annual community-based health check-up conducted from May to June in 2019. In total, 1,040 Japanese adults aged 20–89 years were enrolled in this study. Influenza infection status was determined by participants’ responses to a self-administered questionnaire. The visceral fat area (VFA) was measured using a bioimpedance-type visceral fat meter. Participants were classified into four groups using the following cut-off points: VFA < 100 cm² was set as the reference category according to the Japanese criteria, 100 ≤ VFA < 150 cm², 150 ≤ VFA < 200 cm², and 200 cm² ≤ VFA. Logistic regression models were used to assess the association between VFA and influenza infection.

Results

In total, 119 participants had influenza infections in the past year. In the multivariate adjusted model, a higher VFA was significantly associated with increased influenza infection; the adjusted odds ratio for 200 cm² ≤ VFA was 5.03 [95% confidence interval (CI): 1.07–23.6], that for 150 ≤ VFA < 200 cm² was 1.97 (95% CI: 0.71–5.45), and that for 100 ≤ VFA < 150 cm² was 1.62 (95% CI: 0.84–3.12), compared with that for VFA < 100 cm² (p for trend = 0.049). These findings were confirmed in the same cohort the following year.

Conclusions

Our results suggest that visceral fat accumulation is associated with influenza infection. Large-scale prospective studies using diagnostic information for influenza infection are required to confirm this association.

Role of visceral fat areas defined by thoracic CT in acute pulmonary embolism

OBJECTIVE

Visceral adipose tissue (VAT) has been established as an important parameter of body composition. It can be assessed by imaging modalities like computed tomography (CT). The purpose of the present study was to analyse the prognostic role of VAT derived from thoracic CT in patients with acute pulmonary embolism (PE).

METHODS

The clinical database of our center was retrospectively screened for patients with acute PE between 2014 and 2017. Overall, 184 patients were included into the analysis. VAT was assessed on axial slices of the thoracic CT at the level of the first lumbar vertebra. Clinical scores, serological parameters, need for intubation, ICU admission and 30 days mortality were assessed.

RESULTS

Using the previously reported threshold of 100 cm² for visceral obesity definition 136 (73.9%), patients were considered as visceral obese. There was a moderate correlation between VAT and BMI (r = 0.56, p < 0.0001). There was also a moderate correlation between VAT and body height (r = 0.41, p =< 0.0001). Of all investigated clinical scores relating to acute PE, only the GENEVA score correlated weakly with VAT (r = 0.15, p = 0.04). There were significant correlations between VAT and creatinine (r = 0.38, p < 0.0001) and Glomerular filtration rate (r = -0.21, p = 0.005). No associations were identified for VAT and mortality or visceral obesity and mortality.

CONCLUSION

VAT was not associated with mortality in patients with acute pulmonary embolism.

ADVANCES IN KNOWLEDGE

Visceral obesity is frequent in patients with acute pulmonary embolism but it is not associated with mortality.

Nutritional Risk Assessment Scores Effectively Predict Mortality in Critically Ill Patients with Severe COVID-19

Background: Malnutrition predicts a worse outcome for critically ill patients. However, quick, easy-to-use nutritional risk assessment tools have not been adequately validated. Aims and Methods: The study aimed to evaluate the role of four biological nutritional risk assessment instruments (the Prognostic Nutritional Index—PNI, the Controlling Nutritional Status Score—CONUT, the Nutrition Risk in Critically Ill—NUTRIC, and the modified NUTRIC—mNUTRIC), along with CT-derived fat tissue and muscle mass measurements in predicting in-hospital mortality in a consecutive series of 90 patients hospitalized in the intensive care unit for COVID-19-associated ARDS. Results: In-hospital mortality was 46.7% (n = 42/90). Non-survivors had a significantly higher nutritional risk, as expressed by all four scores. All scores were independent predictors of mortality on the multivariate regression models. PNI had the best discriminative capabilities for mortality, with an area under the curve (AUC) of 0.77 for a cut-off value of 28.05. All scores had an AUC above 0.72. The volume of fat tissue and muscle mass were not associated with increased mortality risk. Conclusions: PNI, CONUT, NUTRIC, and mNUTRIC are valuable nutritional risk assessment tools that can accurately predict mortality in critically ill patients with COVID-19-associated ARDS.

Computed tomography-defined body composition as prognostic markers for unfavourable outcomes and in-hospital mortality in coronavirus disease 2019

BACKGROUND

Low skeletal muscle mass (LSMM) and visceral fat areas can be assessed by cross-sectional images. These parameters are associated with several clinically relevant factors in various disorders with predictive and prognostic implications. Our aim was to establish the effect of computed tomography (CT)-defined LSMM and fat areas on unfavourable outcomes and in-hospital mortality in coronavirus disease 2019 (COVID-19) patients based on a large patient sample.

METHODS

MEDLINE library, Cochrane, and Scopus databases were screened for the associations between CT-defined LSMM as well as fat areas and in-hospital mortality in COVID-19 patients up to September 2021. In total, six studies were suitable for the analysis and included into the present analysis.

RESULTS

The included studies comprised 1059 patients, 591 men (55.8%) and 468 women (44.2%), with a mean age of 60.1 years ranging from 48 to 66 years. The pooled prevalence of LSMM was 33.6%. The pooled odds ratio for the effect of LSMM on in-hospital mortality in univariate analysis was 5.84 [95% confidence interval (CI) 1.07-31.83]. It was 2.73 (95% CI 0.54-13.70) in multivariate analysis. The pooled odds ratio of high visceral fat area on unfavourable outcome in univariate analysis was 2.65 (95% CI 1.57-4.47).

CONCLUSIONS

Computed tomography-defined LSMM and high visceral fat area have a relevant association with in-hospital mortality in COVID-19 patients and should be included as relevant prognostic biomarkers into clinical routine.