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Lucena Valera A, Aller Dela Fuente R, Sánchez Torrijos Y, Romero Gómez M, Ampuero Herrojo J. FIB-4 score as predictor of COVID-19-related severity in hospitalized patients. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024. [PMID: 38767045 DOI: 10.17235/reed.2024.9811/2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
AIM To determine the impact of liver fibrosis on the prognosis of COVID and the liver injury associated with the infection. METHODS Retrospective multicenter study including 575 patients requiring admission for COVID-19 between January and June 2020. FIB-4 was calculated within 6 months prior to infection and at 6 months post-infection. RESULTS Baseline FIB-4 was increased in patients who died (1.91±0.95 vs. 1.43±0.85; p<0.001). In addition, the 17.1% (32/187) of patients with baseline FIB-4<1.45 died versus 52.9% (9/17) if FIB-4>3.25 (p<0.001). In the adjusted multivariate analysis, baseline FIB-4 (OR 1.61 (95%CI 1.19-2.18); p=0.002) was independently associated with mortality. Parameters associated with liver injury, including AST (28±10 vs. 45±56IU/L; p<0.001) and ALT (20±12 vs. 38±48IU/L; p<0.001) were significantly higher at admission compared to baseline. Also, FIB-4 was increased from baseline to the time of admission (1.53±0.88 vs. 2.55±1.91; p<0.001), and up to 6.9% (10/145) of patients with FIB-4<1.45 at admission died versus 47.5% if FIB-4>3.25 (58/122) (p<0.001). In the adjusted multivariate analysis, FIB-4 at admission (OR 1.14 (95%CI 1.03-1.27); p=0.015) was independently associated with mortality. Also, AST (42±38 vs. 22±17IU/L; p<0.001) and ALT (40±50 vs. 20±19 IU/L; p<0.001) were significantly reduced at 6 months after the resolution of infection. Accordingly, FIB-4 decreased significantly (2.12±1.25 vs. 1.32±0.57; p<0.001) six months after the infection. CONCLUSION Increased FIB-4, either at baseline or at the time of admission, was related to the severity and mortality related to SARS-CoV-2 infection. However, the liver damage expressed by elevated transaminases and FIB-4 was reversible in most of patients.
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Albayrak T, Yuksel B. Prognostic Value of Fibrosis 4 (FIB-4) Index in Sepsis Patients. J Pers Med 2024; 14:531. [PMID: 38793113 PMCID: PMC11121996 DOI: 10.3390/jpm14050531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Revised: 05/10/2024] [Accepted: 05/11/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Sepsis remains a major health challenge worldwide, characterized by a dysregulated host response to infection, leading to high mortality and morbidity in intensive care units (ICUs). The Fibrosis 4 (FIB-4) index, originally developed to assess liver fibrosis in hepatitis C patients, has recently been explored for its potential prognostic value in sepsis patients. METHOD this study retrospectively analyzed 309 sepsis patients admitted to the Internal Medicine and An-aesthesia ICUs between 12 December 2021 and 15 December 2023 to investigate the relationship between FIB-4 levels, the Acute Physiology and Chronic Health Evaluation (APACHE), the Sequential Organ Failure Assessment (SOFA), and clinical outcomes. RESULTS This study found that higher FIB-4 measurements were statistically significantly associated with increased 28-day mortality, with a cut-off value of 4.9, providing a sensitivity of 54.92% and specificity of 74.25%. Logistic regression analysis indicated that elevated FIB-4 levels were a significant predictor of early mortality, suggesting that the FIB-4 index could serve as a valuable prognostic tool in assessing the severity and prognosis of sepsis patients. CONCLUSIONS by elucidating the potential role of the FIB-4 index in sepsis prognosis, this study contributes to the ongoing efforts to improve risk stratification and enhance patient care in sepsis management.
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Affiliation(s)
- Tuna Albayrak
- Department of Anesthesiology and Reanimation, Giresun University Faculty of Medicine, Giresun 28200, Türkiye
| | - Beyza Yuksel
- Giresun Training and Research Hospital, Internal Medicine Intensive Care Unit, Giresun 28200, Türkiye;
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Galiero R, Loffredo G, Simeon V, Caturano A, Vetrano E, Medicamento G, Alfano M, Beccia D, Brin C, Colantuoni S, Di Salvo J, Epifani R, Nevola R, Marfella R, Sardu C, Coppola C, Scarano F, Maggi P, Calabrese C, De Lucia Sposito P, Rescigno C, Sbreglia C, Fraganza F, Parrella R, Romano A, Calabria G, Polverino B, Pagano A, Numis F, Bologna C, Nunziata M, Esposito V, Coppola N, Maturo N, Nasti R, Di Micco P, Perrella A, Adinolfi LE, Chiodini P, Di Domenico M, Rinaldi L, Sasso FC. Impact of liver fibrosis on COVID-19 in-hospital mortality in Southern Italy. PLoS One 2024; 19:e0296495. [PMID: 38713731 DOI: 10.1371/journal.pone.0296495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 12/14/2023] [Indexed: 05/09/2024] Open
Abstract
BACKGROUND & AIMS SARS-Cov-2 infection manifests as a wide spectrum of clinical presentation and even now, despite the global spread of the vaccine, contagiousness is still elevated. The aim of the study was the evaluation of the impact of liver fibrosis assessed by FIB-4 and liver impairment, assessed by cytolysis indices, on intrahospital mortality in COVID-19 subjects. METHODS This is a retrospective observational cohort study, which involved 23 COVID Hospital Units in Campania Region, Italy. Exposure variables were collected during hospital admission and at discharge. According to FIB-4 values, we subdivided the overall population in three groups (FIB-4<1.45; 1.453.25), respectively group 1,2,3. RESULTS At the end of the study, 938 individuals had complete discharged/dead data. At admission, 428 patients were in group 1 (45.6%), 387 in group 2 (41.3%) and 123 in group 3 (13.1%). Among them, 758 (81%) subjects were discharged, while the remaining 180 (19%) individuals died. Multivariable Cox's regression model showed a significant association between mortality risk and severity of FIB-4 stages (group 3 vs group 1, HR 2.12, 95%CI 1.38-3.28, p<0.001). Moreover, Kaplan-Meier analysis described a progressive and statistically significant difference (p<0.001 Log-rank test) in mortality according to FIB-4 groups. Among discharged subjects, 507 showed a FIB-4<1.45 (66.9%, group 1), 182 a value 1.453.25 (9.0%, group 3). Among dead subjects, 42 showed a FIB-4<1.45 (23.3%, group 1), 62 a value 1.453.25 (42.3%, group 3). CONCLUSIONS FIB-4 value is significantly associated with intrahospital mortality of COVID-19 patients. During hospitalization, particularly in patients with worse outcomes, COVID-19 seems to increase the risk of acute progression of liver damage.
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Affiliation(s)
- Raffaele Galiero
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Giuseppe Loffredo
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Vittorio Simeon
- Medical Statistics Unit, Department of Physical and Mental Health and Preventive Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Alfredo Caturano
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Erica Vetrano
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Giulia Medicamento
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Maria Alfano
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Domenico Beccia
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Chiara Brin
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Sara Colantuoni
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Jessica Di Salvo
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Raffaella Epifani
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Riccardo Nevola
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
- Ospedale Evangelico Betania, Naples, Italy
| | - Raffaele Marfella
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Celestino Sardu
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Carmine Coppola
- Hepatology Unit, Internal Medicine, Area Stabiese Hospital, Naples, Italy
| | - Ferdinando Scarano
- COVID Center "S. Anna e SS. Madonna della Neve" Hospital, Boscotrecase, Italy
| | - Paolo Maggi
- U.O.C. Infectious and Tropical diseases, S. Anna e S. Sebastiano Hospital, Caserta, Italy
| | - Cecilia Calabrese
- Pneumologia Vanvitelli Department of Translational Medical Sciences, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | | | - Carolina Rescigno
- U.O.C. Infectious Diseases and Neurology, Cotugno Hospital, Naples, Italy
| | - Costanza Sbreglia
- U.O.C. Infectious Diseases of the Elderly, Cotugno Hospital, Naples, Italy
| | | | - Roberto Parrella
- U.O.C. Respiratory Infectious Diseases, Cotugno Hospital, Naples, Italy
| | | | - Giosuele Calabria
- IXth Division of Infectious Diseases and Interventional Ultrasound, Cotugno Hospital, Naples, Italy
| | | | - Antonio Pagano
- Emergency and Acceptance Unit, "Santa Maria delle Grazie" Hospital, Pozzuoli, Italy
| | - Fabio Numis
- Emergency and Acceptance Unit, "Santa Maria delle Grazie" Hospital, Pozzuoli, Italy
| | | | | | - Vincenzo Esposito
- IVth Division of Immunodeficiency and Gender Infectious Diseases, Cotugno Hospital, Naples, Italy
| | - Nicola Coppola
- Department of Mental Health and Public Medicine, Centro COVID A.O.U. Vanvitelli, Naples, Italy
| | - Nicola Maturo
- U.O.S.D. Infectious Diseases Emergency and Acceptance, Cotugno Hospital, Naples, Italy
| | - Rodolfo Nasti
- Emergency Division, A.O.R.N. "Antonio Cardarelli", Naples, Italy
| | - Pierpaolo Di Micco
- Department of Internal Medicine, Fatebenefratelli Hospital of Naples, Naples, Italy
| | | | - Luigi Elio Adinolfi
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Paolo Chiodini
- Medical Statistics Unit, Department of Physical and Mental Health and Preventive Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Marina Di Domenico
- Department of Precision Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Luca Rinaldi
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Ferdinando Carlo Sasso
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
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Buchynskyi M, Oksenych V, Kamyshna I, Kamyshnyi O. Exploring Paxlovid Efficacy in COVID-19 Patients with MAFLD: Insights from a Single-Center Prospective Cohort Study. Viruses 2024; 16:112. [PMID: 38257811 PMCID: PMC10819977 DOI: 10.3390/v16010112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/04/2024] [Accepted: 01/10/2024] [Indexed: 01/24/2024] Open
Abstract
This study investigates the intricate interplay between Metabolic-associated Fatty Liver Disease (MAFLD) and COVID-19, exploring the impact of MAFLD on disease severity, outcomes, and the efficacy of the antiviral agent Paxlovid (nirmatrelvir/ritonavir). MAFLD, affecting a quarter of the global population, emerges as a potential risk factor for severe COVID-19, yet the underlying pathophysiological mechanisms remain elusive. This study focuses on the clinical significance of Paxlovid, the first orally bioavailable antiviral agent granted Emergency Use Authorization in the United States. Notably, outcomes from phase II/III trials exhibit an 88% relative risk reduction in COVID-19-associated hospitalization or mortality among high-risk patients. Despite conflicting data on the association between MAFLD and COVID-19 severity, this research strives to bridge the gap by evaluating the effectiveness of Paxlovid in MAFLD patients with COVID-19, addressing the scarcity of relevant studies.
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Affiliation(s)
- Mykhailo Buchynskyi
- Department of Microbiology, Virology, and Immunology, I. Horbachevsky Ternopil National Medical University, 46001 Ternopil, Ukraine
| | - Valentyn Oksenych
- Broegelmann Research Laboratory, Department of Clinical Science, University of Bergen, 5020 Bergen, Norway
| | - Iryna Kamyshna
- Department of Medical Rehabilitation, I. Horbachevsky Ternopil National Medical University, 46001 Ternopil, Ukraine
| | - Oleksandr Kamyshnyi
- Department of Microbiology, Virology, and Immunology, I. Horbachevsky Ternopil National Medical University, 46001 Ternopil, Ukraine
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Golla K, Benesic A, Mannell H, Dreischulte T, Grill E, Strobach D. Hepatic Impairment as a Risk Factor for Drug Safety: Suitability and Comparison of Four Liver Scores as Screening Tools. J Clin Med 2023; 12:6814. [PMID: 37959279 PMCID: PMC10649763 DOI: 10.3390/jcm12216814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/19/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
Hepatic impairment (HI) influences the pharmacokinetics and pharmacodynamics of drugs and represents an important risk factor for drug safety. A reliable screening tool for HI identification at hospital admission by pharmacists would be desirable but is currently lacking. Therefore, we tested four liver scores as potential screening instruments. We retrospectively recorded liver/bile diagnoses, symptoms and abnormalities (summarized as hepatic findings) of 200 surgical patients followed by an assessment of the relevance of these findings for drug therapy (rating). The agreement between the Model of Endstage Liver Disease (MELD), Non-alcoholic fatty liver disease fibrosis score (NFS), Fibrosis 4 index (FIB-4), and aspartate-aminotransferase to platelet ratio index (APRI) and the rating was quantified by Cohen's Kappa. The performance of the scores in this setting was further evaluated by their sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Of 200 patients, 18 (9%) had hepatic findings relevant for drug therapy. Fair agreement was found for FIB-4 and MELD and slight agreement for APRI and NFS compared to the rating. The highest values for sensitivity, specificity, PPV, and NPV were 41.2% (MELD), 99.3% (APRI), 66.7% (APRI), and 93.6% (MELD), respectively. Due to low performance, none of the scores can be recommended for clinical use as a single screening tool for HI at hospital admission.
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Affiliation(s)
- Kathrin Golla
- Doctoral Program Clinical Pharmacy, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
- Hospital Pharmacy, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Andreas Benesic
- Department of Internal Medicine—Gastroenterology, Krankenhaus GmbH Weilheim-Schongau, Marie-Eberth Str. 6, 86956 Schongau, Germany
| | - Hanna Mannell
- Doctoral Program Clinical Pharmacy, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
- Department of Physiology, Institute for Theoretical Medicine, University of Augsburg, 86159 Augsburg, Germany
| | - Tobias Dreischulte
- Institute of General Practice and Family Medicine, University Hospital, LMU Munich, Pettenkoferstr. 8a, 80336 Munich, Germany
| | - Eva Grill
- Institute for Medical Information Processing, Biometrics and Epidemiology, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Dorothea Strobach
- Doctoral Program Clinical Pharmacy, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
- Hospital Pharmacy, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
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Jagirdhar GSK, Pattnaik H, Banga A, Qasba RK, Rama K, Reddy ST, Bucharles ACF, Kashyap R, Elmati PR, Bansal V, Bains Y, DaCosta T, Surani S. Association of Non-Alcoholic Fatty Liver Disease and Metabolic-Associated Fatty Liver Disease with COVID-19-Related Intensive Care Unit Outcomes: A Systematic Review and Meta-Analysis. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1239. [PMID: 37512051 PMCID: PMC10386363 DOI: 10.3390/medicina59071239] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/13/2023] [Accepted: 06/27/2023] [Indexed: 07/30/2023]
Abstract
Background and Objective: The association of non-alcoholic fatty liver disease (NAFLD) and metabolic-associated fatty liver disease (MAFLD) with intensive care unit (ICU) admissions and the need for mechanical ventilation and disease severity in COVID-19 patients. Material and Methods: A systematic literature review was conducted on the databases: Cochrane, Embase, PubMed, ScienceDirect, and the Web of Science from January 2019 to June 2022. Studies evaluating MAFLD using laboratory methods, non-invasive imaging, or liver biopsy were included. The study protocol was registered in PROSPERO (ID CRD42022313259), and PRISMA guidelines were followed. The NIH quality assessment tool was used for quality assessment. RevMan version 5.3 software was used for pooled analysis. A sensitivity analysis was performed to assess the result's stability. Results: A total of 37,974 patients from 17 studies were assessed for the association between MAFLD and ICU admission. A total of 3396 COVID-19 patients required ICU admission: 1236 (20.41%) in the MAFLD group and 2160 (6.77%) in the non-MAFLD group. The odds ratio was 1.86 for ICU admission, p = 0.007, and a (95% CI) of [1.18-2.91]. A total of 37,166 patients from 13 studies were included in the need for invasive mechanical ventilation analysis. A total of 1676 patients required mechanical ventilation: 805 in the MAFLD group (14.20% of all MAFLD patients) and 871 patients in the non-MAFLD group (2.76% of all non-MAFLD patients). The odds ratio was 2.05, p = 0.02, and a (95% CI) of [1.12-3.74]. A total of 5286 patients from 14 studies were included in the COVID-19 disease severity analysis. Severe COVID-19 was seen in 1623 patients, with 33.17% (901/2716) of MAFLD patients and 28.09% (722/2570) of non-MAFLD patients having severe disease. The odds ratio was 1.59 for disease severity, p = 0.010, and a (95% CI) of [1.12-2.26]. Conclusions: Our meta-analysis suggests that there are significantly increased odds of ICU admissions, a need for invasive mechanical ventilation, and disease severity in MAFLD patients who acquire COVID-19.
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Affiliation(s)
| | | | - Akshat Banga
- Sawai Man Singh Medical College, Jaipur 302004, India
| | - Rakhtan K Qasba
- Green Life Medical College and Hospital, Dhaka 1205, Bangladesh
| | | | | | | | - Rahul Kashyap
- Critical Care Medicine, Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, USA
| | - Praveen Reddy Elmati
- Interventional Pain Medicine, University of Louisville, Louisville, KY 40202, USA
| | - Vikas Bansal
- Division of Nephrology and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Yatinder Bains
- Department of Gastroenterology, Saint Michaels Medical Center, Newark, NJ 07102, USA
| | - Theodore DaCosta
- Department of Gastroenterology, Saint Michaels Medical Center, Newark, NJ 07102, USA
| | - Salim Surani
- Pulmonary, Critical Care & Pharmacy, Texas A&M University, College Station, TX 79016, USA
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Hatipoğlu D, Mulligan C, Wang J, Peticco J, Grinspoon R, Gadi S, Mills C, Luther J, Chung RT. Differential Effects of COVID-19 Hospitalization on the Trajectory of Liver Disease Progression. GASTRO HEP ADVANCES 2023; 2:480-486. [PMID: 36816340 PMCID: PMC9922433 DOI: 10.1016/j.gastha.2023.01.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 02/24/2023]
Abstract
Background and Aims Patients with chronic liver disease (CLD) were significantly affected by COVID-19. Despite evidence of acute hepatic injury and increased mortality, the long-term effects of COVID-19 hospitalization on the natural history of CLD patients are unknown. Methods The Massachusetts General Hospital COVID-19 registry was used to obtain a cohort of CLD patients hospitalized between March 8 and June 3, 2020. The Partners Research Patient Data Registry was used to develop a matched CLD patient control list without COVID-19. Fibrosis-4 index (FIB-4), nonalcoholic fatty liver disease fibrosis score (NFS), and model for end-stage liver disease/Na (MELD-Na) scores were calculated pre-, day of, and 1-year post-discharge from admission. Unpaired t-test was used to compare continuous variables. Results Fifty-two COVID-19 patients and 92 control patients with CLD were included. Patients with non-cirrhotic CLD who were hospitalized for COVID-19 had an acute rise in FIB-4 on admission with subsequent improvement on one-year follow-up demonstrating no difference in progression of liver disease compared to the controls (P = .87, confidence interval [CI] -0.088 to 0.048). Similar trends were observed in nonalcoholic fatty liver disease patients using NFS (P = .48, CI -0.016 to 0.023). In contrast, patients with cirrhosis experienced rise in MELD-Na postadmission compared to the control cirrhosis group (0.35 vs -0.076/month; P = .04, CI -0.827 to -0.025), suggesting a potential for long-term consequences of COVID-19. Conclusion Non-cirrhotic CLD patients who survive COVID-19 hospitalization do not appear to have change in FIB-4, NFS scores at one year. However, patients with cirrhosis exhibit increasing MELD-Na one-year post-COVID suggesting a differential effect of acute COVID-19 on the trajectory of established cirrhosis.
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Affiliation(s)
- Dilara Hatipoğlu
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Connor Mulligan
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Liver Center, Massachusetts General Hospital, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Jeffrey Wang
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Liver Center, Massachusetts General Hospital, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Juan Peticco
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Liver Center, Massachusetts General Hospital, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Reid Grinspoon
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Sanjay Gadi
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Camilla Mills
- Division of Gastroenterology, Department of Pediatrics, Hepatology, and Nutrition, Boston Children’s Hospital, Boston, Massachusetts
| | - Jay Luther
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Liver Center, Massachusetts General Hospital, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Raymond T. Chung
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Liver Center, Massachusetts General Hospital, Boston, Massachusetts
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Walia D, Saraya A, Gunjan D. COVID-19 in patients with pre-existing chronic liver disease – predictors of outcomes. World J Virol 2023; 12:30-43. [PMID: 36743659 PMCID: PMC9896592 DOI: 10.5501/wjv.v12.i1.30] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/19/2022] [Accepted: 12/06/2022] [Indexed: 01/18/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) has affected patients with pre-existing chronic liver disease (CLD) in various ways. The maximum impact was seen on patients with underlying cirrhosis who have shown to have poor clinical outcomes in the form of increased risk of hepatic decompensation, acute-on-chronic liver failure, and even mortality. It is of paramount importance to identify various factors which are associated with unfavorable outcomes for prognostication and making informed management strategy. Many factors have been evaluated in different studies in patients with underlying CLD. Some of these factors include the severity of underlying chronic liver disease, comorbid conditions, age, and severity of COVID-19. Overall, the outcomes are not fav-orable in patients with cirrhosis as evidenced by data from various studies. The main purpose of this review is to identify the predictors of adverse clinical outcomes including mortality in patients with CLD for risk stratification, prognostication, and appropriate clinical management.
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Affiliation(s)
- Dinesh Walia
- Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi 110029, New Delhi, India
| | - Anoop Saraya
- Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi 110029, New Delhi, India
| | - Deepak Gunjan
- Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi 110029, New Delhi, India
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9
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Aditianingsih D, Soenarto RF, Puiantana AM, Pranata R, Lim MA, Raharja PAR, Birowo P, Meyer M. Dose response relationship between D-dimer level and mortality in critically ill COVID-19 patients: a retrospective observational study. F1000Res 2023; 11:269. [PMID: 38665691 PMCID: PMC11043662 DOI: 10.12688/f1000research.108972.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/19/2022] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) is a global pandemic. Coagulopathy is one of the most common complications characterized by increased D-dimer level. We aimed to investigate the dose-response relationship between elevated D-dimer level and mortality in critically ill COVID-19 patients. METHODS This was a retrospective observational study in 259 critically ill COVID-19 patients requiring intensive care unit admission between March and December 2020. We compared the mortality rate between patients with and without elevated D-dimer. Receiver operating characteristic (ROC) curve analysis, Fagan's nomogram, and dose-response relationship were performed to determine the association between D-dimer level and mortality. RESULTS Overall mortality rate was 40.9% (106 patients). Median D-dimer level was higher in non-survivor group (10,170 ng/mL vs 4,050 ng/mL, p=0.028). The association remained significant after multivariate logistic regression analysis (p=0.046). The optimal cut-off for D-dimer level to predict mortality from ROC curve analysis was 9,020 ng/mL (OR (odds ratio) 3.73 [95% CI (confidence interval) 1.91 - 7.28], p<0.001). D-dimer level >9,020 ng/mL confers 67% posterior probability of mortality and D-dimer level <9,020 ng/mL had 35% probability of mortality. CONCLUSIONS There was a non-linear dose-response relationship between D-dimer level and mortality with P nonlinearity of 0.004. D-dimer level was associated with mortality in critically ill COVID-19 patients in the non-linear dose-response relationship.
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Affiliation(s)
- Dita Aditianingsih
- Division of Critical Care, Universitas Indonesia Hospita, Depok, Jawa Barat, Indonesia
- Department of Anesthesia and Intensive Care, Dr. Cipto Mangunkusumo Hospital – Universitas Indonesia Hospital, Jakarta, DKI Jakarta, Indonesia
| | - Ratna Farida Soenarto
- Department of Anesthesia and Intensive Care, Dr. Cipto Mangunkusumo Hospital – Universitas Indonesia Hospital, Jakarta, DKI Jakarta, Indonesia
| | - Artheta Mutiara Puiantana
- Department of Anesthesia and Intensive Care, Dr. Cipto Mangunkusumo Hospital – Universitas Indonesia Hospital, Jakarta, DKI Jakarta, Indonesia
| | - Raymond Pranata
- Faculty of Medicine, Pelita Harapan University, Tangerang, Banten, Indonesia
| | | | - Putu Angga Risky Raharja
- Department of Urology, Dr. Cipto Mangunkusumo Hospital – Universitas Indonesia Hospital, Jakarta, DKI Jakarta, Indonesia
| | - Ponco Birowo
- Department of Urology, Dr. Cipto Mangunkusumo Hospital – Universitas Indonesia Hospital, Jakarta, DKI Jakarta, Indonesia
| | - Markus Meyer
- Faculty of Medicine, Universitas Indonesia, Jakarta, DKI Jakarta, Indonesia
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Canillas L, Puigvehí M. Reply to: 'Abnormal liver function tests and coronavirus disease 2019: A close relationship'. J Viral Hepat 2023; 30:81. [PMID: 36367344 PMCID: PMC9877927 DOI: 10.1111/jvh.13773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 11/03/2022] [Indexed: 11/13/2022]
Affiliation(s)
- Lidia Canillas
- Liver Section, Gastroenterology DepartmentHospital del MarBarcelonaSpain,IMIM (Hospital del Mar Medical Research Institute)BarcelonaSpain
| | - Marc Puigvehí
- Liver Section, Gastroenterology DepartmentHospital del MarBarcelonaSpain,IMIM (Hospital del Mar Medical Research Institute)BarcelonaSpain
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11
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Bali T, Georgakopoulou VE, Kamiliou A, Vergos I, Adamantou M, Vlachos S, Ermidis G, Sipsas NV, Samarkos M, Cholongitas E. Abnormal liver function tests and coronavirus disease 2019: A close relationship. J Viral Hepat 2023; 30:79-80. [PMID: 36369662 PMCID: PMC9878169 DOI: 10.1111/jvh.13772] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 08/02/2022] [Indexed: 11/14/2022]
Affiliation(s)
- Triada Bali
- First Department of Internal Medicine, Laiko General HospitalMedical School of National and Kapodistrian University of AthensAthensGreece
| | - Vasiliki E. Georgakopoulou
- Pulmonology Department, Laiko General Hospital, Medical SchoolNational and Kapodistrian University of AthensAthensGreece,Infectious Diseases and COVID‐19 Unit, Laiko General HospitalMedical School of National and Kapodistrian University of AthensAthensGreece
| | - Aikaterini Kamiliou
- First Department of Internal Medicine, Laiko General HospitalMedical School of National and Kapodistrian University of AthensAthensGreece
| | - Ioannis Vergos
- First Department of Internal Medicine, Laiko General HospitalMedical School of National and Kapodistrian University of AthensAthensGreece
| | - Magdalini Adamantou
- First Department of Internal Medicine, Laiko General HospitalMedical School of National and Kapodistrian University of AthensAthensGreece
| | - Stefanos Vlachos
- First Department of Internal Medicine, Laiko General HospitalMedical School of National and Kapodistrian University of AthensAthensGreece
| | - George Ermidis
- First Department of Internal Medicine, Laiko General HospitalMedical School of National and Kapodistrian University of AthensAthensGreece
| | - Nikolaos V. Sipsas
- Infectious Diseases and COVID‐19 Unit, Laiko General HospitalMedical School of National and Kapodistrian University of AthensAthensGreece,Pathophysiology Department, Medical SchoolNational and Kapodistrian University of Athens, and General Hospital of Athens LaikoAthensGreece
| | - Michael Samarkos
- First Department of Internal Medicine, Laiko General HospitalMedical School of National and Kapodistrian University of AthensAthensGreece,Infectious Diseases and COVID‐19 Unit, Laiko General HospitalMedical School of National and Kapodistrian University of AthensAthensGreece
| | - Evangelos Cholongitas
- First Department of Internal Medicine, Laiko General HospitalMedical School of National and Kapodistrian University of AthensAthensGreece
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12
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Prognostic Impact of Myosteatosis on Mortality in Hospitalized Patients with COVID-19. Diagnostics (Basel) 2022; 12:diagnostics12092255. [PMID: 36140656 PMCID: PMC9497568 DOI: 10.3390/diagnostics12092255] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 09/15/2022] [Accepted: 09/16/2022] [Indexed: 01/08/2023] Open
Abstract
Body composition, including sarcopenia, adipose tissue, and myosteatosis, is associated with unfavorable clinical outcomes in patients with coronavirus disease (COVID-19). However, few studies have identified the impact of body composition, including pre-existing risk factors, on COVID-19 mortality. Therefore, this study aimed to evaluate the effect of body composition, including pre-existing risk factors, on mortality in hospitalized patients with COVID-19. This two-center retrospective study included 127 hospitalized patients with COVID-19 who underwent unenhanced chest computed tomography (CT) between February and April 2020. Using the cross-sectional CT images at the L2 vertebra level, we analyzed the body composition, including skeletal muscle mass, visceral to subcutaneous adipose tissue ratio (VSR), and muscle density using the Hounsfield unit (HU). Of 127 patients with COVID-19, 16 (12.6%) died. Compared with survivors, non-survivors had low muscle density (41.9 vs. 32.2 HU, p < 0.001) and high proportion of myosteatosis (4.5 vs. 62.5%, p < 0.001). Cox regression analyses revealed diabetes (hazard ratio [HR], 3.587), myosteatosis (HR, 3.667), and a high fibrosis-4 index (HR, 1.213) as significant risk factors for mortality in patients with COVID-19. Myosteatosis was associated with mortality in hospitalized patients with COVID-19, independent of pre-existing prognostic factors.
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13
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Lombardi R, Mura VL, Cespiati A, Iuculano F, Sigon G, Pallini G, Proietti M, Motta I, Montinaro B, Fiorelli E, Cesari M, Bandera A, Valenti L, Peyvandi F, Montano N, Baldini M, Fracanzani AL. Usefulness of fibrosis-4 (FIB-4) score and metabolic alterations in the prediction of SARS-CoV-2 severity. Intern Emerg Med 2022; 17:1739-1749. [PMID: 35754075 PMCID: PMC9244481 DOI: 10.1007/s11739-022-03000-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 05/06/2022] [Indexed: 01/08/2023]
Abstract
Despite vaccination programs, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection remains a public health problem. Identifying key prognostic determinants of severity of the disease may help better focus health resources. The negative prognostic role for metabolic and hepatic alterations is established; however, the interplay among different metabolic comorbidities and their interconnections with the liver have never been explored.The objective of this study is to evaluate the impact of liver alterations in addition to metabolic comorbidities as a predictor of SARS-CoV-2 severity. 382 SARS-CoV-2 patients were enrolled. Severe SARS-CoV-2 was diagnosed according to international consensus. Transaminases > 2 times the upper limit of normality (2ULN), hepatic steatosis (by ultrasound and/or computed tomography in 133 patients), and FIB-4 defined liver alterations. All data were collected on admission. The results are severe SARS-CoV-2 infection in 156 (41%) patients (mean age 65 ± 17; 60%males). Prevalence of obesity was 25%; diabetes, 17%; hypertension, 44%; dyslipidaemia, 29%; with 13% of the cohort with ≥ 3 metabolic alterations. Seventy patients (18%) had transaminases > 2ULN, 82 (62%) steatosis; 199 (54%) had FIB-4 < 1.45 and 45 (12%) > 3.25. At multivariable analysis, ≥ 3 metabolic comorbidities (OR 4.1, CI 95% 1.8-9.1) and transaminases > 2ULN (OR 2.6, CI 95% 1.3-6.7) were independently associated with severe SARS-CoV-2. FIB-4 < 1.45 was a protective factor (OR 0.42, CI 95% 0.23-0.76). Hepatic steatosis had no impact on disease course. The presence of metabolic alterations is associated with severe SARS-CoV-2 infection, and the higher the number of coexisting comorbidities, the higher the risk of severe disease. Normal FIB-4 values are inversely associated with advanced SARS-CoV-2 regardless of metabolic comorbidities, speculating on use of these values to stratify the risk of severe infection.
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Affiliation(s)
- Rosa Lombardi
- Unit of Internal Medicine and Metabolic Diseases, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
- Department of Pathophysiology and Transplantation, Università Degli Studi di Milano, Via F. SFORZA 35, 20122, Milan, Italy.
| | - Vincenzo La Mura
- Unit of Internal Medicine Hemostasis and Thrombosis, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy
| | - Annalisa Cespiati
- Unit of Internal Medicine and Metabolic Diseases, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università Degli Studi di Milano, Via F. SFORZA 35, 20122, Milan, Italy
| | - Federica Iuculano
- Unit of Internal Medicine and Metabolic Diseases, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università Degli Studi di Milano, Via F. SFORZA 35, 20122, Milan, Italy
| | - Giordano Sigon
- Unit of Internal Medicine and Metabolic Diseases, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università Degli Studi di Milano, Via F. SFORZA 35, 20122, Milan, Italy
| | - Giada Pallini
- Unit of Internal Medicine and Metabolic Diseases, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università Degli Studi di Milano, Via F. SFORZA 35, 20122, Milan, Italy
| | - Marco Proietti
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Irene Motta
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
- Unit of Internal Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Beatrice Montinaro
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
- Unit of Internal Medicine and Immunology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elisa Fiorelli
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
- Unit of Internal Medicine and Immunology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Matteo Cesari
- Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Alessandra Bandera
- Department of Pathophysiology and Transplantation, Università Degli Studi di Milano, Via F. SFORZA 35, 20122, Milan, Italy
- Unit of Infectious Diseases, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Luca Valenti
- Department of Pathophysiology and Transplantation, Università Degli Studi di Milano, Via F. SFORZA 35, 20122, Milan, Italy
- Department of Transfusion Medicine and Hematology, Università degli Studi di Milano, Milan, Italy
| | - Flora Peyvandi
- Department of Pathophysiology and Transplantation, Università Degli Studi di Milano, Via F. SFORZA 35, 20122, Milan, Italy
- Unit of Internal Medicine Hemostasis and Thrombosis, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Montano
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
- Unit of Internal Medicine and Immunology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marina Baldini
- Unit of Internal Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Anna Ludovica Fracanzani
- Unit of Internal Medicine and Metabolic Diseases, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università Degli Studi di Milano, Via F. SFORZA 35, 20122, Milan, Italy
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14
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Zein AFMZ, Raffaello WM. Dipeptidyl peptidase-4 (DPP-IV) inhibitor was associated with mortality reduction in COVID-19 - A systematic review and meta-analysis. Prim Care Diabetes 2022; 16:162-167. [PMID: 34952805 PMCID: PMC8666291 DOI: 10.1016/j.pcd.2021.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 12/06/2021] [Accepted: 12/10/2021] [Indexed: 02/06/2023]
Abstract
INTRODUCTION This systematic review and meta-analysis aimed to synthesize the latest evidence on the effect of dipeptidyl peptidase-4 (DPP-IV) inhibitor in patients with COVID-19. METHODS We performed a systematic literature search from the PubMed, Scopus, Embase, and Clinicaltrials.gov up until 15 July 2021. Studies that met the following criteria were included: prospective or retrospective observational studies or case series or randomized controlled trials (RCTs) reporting DPP-IV inhibitor use in patients with COVID-19 and mortality. The intervention group was patients receiving DPP-IV inhibitor. The control group was patients that did not receive DPP-IV inhibitor. The outcome was mortality reported as odds ratio (OR). RESULTS There were 11 studies consisting of 5950 patients in this meta-analysis. DPP-IV inhibitor use was associated with reduced mortality (OR 0.75 [0.56, 0.99], p = 0.043, I2: 42.9, p = 0.064) compared to those that did not receive DPP-IV inhibitor. Sensitivity analysis using the fixed-effect model (OR 0.75 [0.63, 0.88], p < 0.001, I2: 42.9, p = 0.064) also showed mortality benefit. The association between DPP-IV inhibitor and mortality was not significantly affected by age (p = 0.540), sex (p = 0.054), hypertension (p = 0.320), location (continent; p = 0.532), and retrospective/prospective nature of the study (p = 0.840). However, the association was affected by metformin (OR 1.03 [95% CI 1.01, 1.06], p = 0.010) and ACEI/ARB use (OR 1.06 [95% CI 1.02, 1.10], p = 0.004). CONCLUSION This meta-analysis showed that DPP-IV inhibitor was associated with reduced mortality in patients with COVID-19.
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Affiliation(s)
- Ahmad Fariz Malvi Zamzam Zein
- Department of Internal Medicine, Faculty of Medicine, Universitas Swadaya Gunung Jati, Cirebon, Indonesia; Department of Internal Medicine, Waled General Hospital, Cirebon, Indonesia.
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15
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Zein AFMZ, Raffaello WM. Effect of colchicine on mortality in patients with COVID-19 - A systematic review and meta-analysis. Diabetes Metab Syndr 2022; 16:102395. [PMID: 35078098 PMCID: PMC8752163 DOI: 10.1016/j.dsx.2022.102395] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/06/2022] [Accepted: 01/08/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIM This systematic review and meta-analysis aimed to evaluate the latest evidence on the association between colchicine and mortality in patients with COVID-19. METHODS We performed a comprehensive literature search from the PubMed, Scopus, Embase, EuropePMC, and Clinicaltrials.gov up until 02 January 2022. We include randomized controlled trials (RCTs) and observational studies reporting colchicine use in patients with COVID-19 and mortality within 30 days. The intervention group was patients given colchicine during the course of treatment. The control group was patients given placebo or standard of care at the respective institutions. The outcome was mortality. The effect estimate was reported as risk ratio (RR). RESULTS There were 12 studies comprising of 6953 patients included in this meta-analysis. Mortality rate was 0.18 [95%CI 0.10, 0.26] in the colchicine group and 0.26 [95%CI 0.15, 0.38] in the control group. Colchicine was associated with reduction in mortality (RR 0.66 [95%CI 0.53, 0.83], p < 0.001; I2: 42%). Sensitivity analysis using fixed-effect model (RR 0.73 [95%CI 0.63, 0.83], p < 0.001; I2: 42%. Subgroup analysis on the four RCTs showed non-significant result (RR 0.81 [95%CI 0.54, 1.20], p = 0.29; I2: 10%). Meta-regression showed that the association between colchicine and reduced mortality was not affected by age (p = 0.613) [Fig. 3], sex (p = 0.915), diabetes (p = 0.795), and hypertension (p = 0.403). CONCLUSION Though the meta-analysis showed decreased mortality with colchicine in patients with COVID-19, the meta-analysis of randomized trials did not show any significant effect of colchicine on mortality.
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Affiliation(s)
- Ahmad Fariz Malvi Zamzam Zein
- Department of Internal Medicine, Faculty of Medicine, Universitas Swadaya Gunung Jati, Cirebon, Indonesia; Department of Internal Medicine, Waled General Hospital, Cirebon, Indonesia.
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16
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Demir N, Yüzbasıoglu B, Calhan T, Ozturk S. Prevalence and Prognostic Importance of High Fibrosis-4 Index in COVID-19 Patients. Int J Clin Pract 2022; 2022:1734896. [PMID: 35685537 PMCID: PMC9159137 DOI: 10.1155/2022/1734896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 02/07/2022] [Accepted: 03/29/2022] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION The fibrosis 4 (FIB-4) index was developed to predict advanced fibrosis in patients with liver disease. We aimed to evaluate the association of FIB-4 with risk factors for progression to critical illness in middle-aged patients hospitalized for coronavirus disease 2019 (COVID-19). METHOD We included patients aged 35-65 years who were hospitalized following a positive RT-PCR SARS-Cov-2 test in a tertiary hospital. All data were obtained from the medical records of the patients during the first admission to the hospital. The FIB-4 index was calculated according to the equation (age (years) x AST (IU/L)/platelet count (109/L)/√ALT (IU/L)). The FIB-4 index was divided into three categories according to the score categorisation: <1.3 = low risk, 1.3-2.67 = moderate risk, and >2.67 = high risk. RESULTS A total of 619 confirmed COVID-19 patients (mean age = 52 yrs.) were included in this study; 37 (6.0%) were admitted to the intensive care unit (ICU), of which 44% were intubated and eight (1.3%) patients died during follow-up. The results of patients with high FIB-4 scores were compared with those with low FIB-4 scores. In patients with high FIB-4 scores, male gender, and advanced age, decreased neutrophil, lymphocyte, thrombocyte, and albumin counts, elevated AST, LDH, CK, ferritin, CRP, and D-dimer, and low GFR were the high-risk factors for critical illness. Additionally, the number of patients referred to ICU with high FIB-4 who died had higher scores than from those with low scores. CONCLUSION The FIB-4 index derived from baseline data obtained during hospitalisation can be used as a simple, inexpensive, and straightforward indicator to predict ICU requirement and/or death in middle-aged hospitalized COVID-19 patients.
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Affiliation(s)
- Nurhan Demir
- Department of Gastroenterology, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Bilgehan Yüzbasıoglu
- Department of Gastroenterology, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Turan Calhan
- Department of Gastroenterology, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Savas Ozturk
- Department of Internal Medicine, Division of Nephrology, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey
- Department of Nephrology, Haseki Training and Research Hospital, Istanbul, Turkey
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17
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Crisan D, Avram L, Grapa C, Dragan A, Radulescu D, Crisan S, Grosu A, Militaru V, Buzdugan E, Stoicescu L, Radulescu L, Ciovicescu F, Jivanescu DB, Mocan O, Micu B, Donca V, Marinescu L, Macarie A, Rosu M, Nemes A, Craciun R. Liver Injury and Elevated FIB-4 Define a High-Risk Group in Patients with COVID-19. J Clin Med 2021; 11:153. [PMID: 35011894 PMCID: PMC8745798 DOI: 10.3390/jcm11010153] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/16/2021] [Accepted: 12/24/2021] [Indexed: 02/07/2023] Open
Abstract
Liver involvement in Coronavirus Disease 2019 (COVID-19) has been widely documented. However, data regarding liver-related prognosis are scarce and heterogeneous. The current study aims to evaluate the role of abnormal liver tests and incidental elevations of non-invasive fibrosis estimators on the prognosis of hospitalized COVID-19 patients. We conducted a retrospective cohort study to investigate the impact of elevated liver tests, non-invasive fibrosis estimators (the Fibrosis-4 (FIB-4), Forns, APRI scores, and aspartate aminotransferase/alanine aminotransferase (AST/ALT) ratio), and the presence of computed tomography (CT)-documented liver steatosis on mortality in patients with moderate and severe COVID-19, with no prior liver disease history. A total of 370 consecutive patients were included, of which 289 patients (72.9%) had abnormal liver biochemistry on admission. Non-survivors had significantly higher FIB-4, Forns, APRI scores, and a higher AST/ALT ratio. On multivariate analysis, severe FIB-4 (exceeding 3.25) and elevated AST were independently associated with mortality. Severe FIB-4 had an area under the receiver operating characteristic (AUROC) of 0.73 for predicting survival. The presence of steatosis was not associated with a worse outcome. Patients with abnormal liver biochemistry on arrival might be susceptible to a worse disease outcome. An FIB-4 score above the threshold of 3.25, suggestive of the presence of fibrosis, is associated with higher mortality in hospitalized COVID-19 patients.
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Affiliation(s)
- Dana Crisan
- Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (D.C.); (A.D.); (D.R.); (S.C.); (A.G.); (V.M.); (E.B.); (L.S.); (L.R.); (F.C.); (D.B.J.); (O.M.); (B.M.); (V.D.); (L.M.); (A.M.); (M.R.); (R.C.)
- Department of Internal Medicine, Clinical Municipal Hospital Cluj-Napoca, 400139 Cluj-Napoca, Romania
| | - Lucretia Avram
- Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (D.C.); (A.D.); (D.R.); (S.C.); (A.G.); (V.M.); (E.B.); (L.S.); (L.R.); (F.C.); (D.B.J.); (O.M.); (B.M.); (V.D.); (L.M.); (A.M.); (M.R.); (R.C.)
- Department of Internal Medicine, Clinical Municipal Hospital Cluj-Napoca, 400139 Cluj-Napoca, Romania
| | - Cristiana Grapa
- Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (D.C.); (A.D.); (D.R.); (S.C.); (A.G.); (V.M.); (E.B.); (L.S.); (L.R.); (F.C.); (D.B.J.); (O.M.); (B.M.); (V.D.); (L.M.); (A.M.); (M.R.); (R.C.)
| | - Alexandra Dragan
- Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (D.C.); (A.D.); (D.R.); (S.C.); (A.G.); (V.M.); (E.B.); (L.S.); (L.R.); (F.C.); (D.B.J.); (O.M.); (B.M.); (V.D.); (L.M.); (A.M.); (M.R.); (R.C.)
| | - Dan Radulescu
- Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (D.C.); (A.D.); (D.R.); (S.C.); (A.G.); (V.M.); (E.B.); (L.S.); (L.R.); (F.C.); (D.B.J.); (O.M.); (B.M.); (V.D.); (L.M.); (A.M.); (M.R.); (R.C.)
- Department of Internal Medicine, Clinical Municipal Hospital Cluj-Napoca, 400139 Cluj-Napoca, Romania
| | - Sorin Crisan
- Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (D.C.); (A.D.); (D.R.); (S.C.); (A.G.); (V.M.); (E.B.); (L.S.); (L.R.); (F.C.); (D.B.J.); (O.M.); (B.M.); (V.D.); (L.M.); (A.M.); (M.R.); (R.C.)
- Department of Internal Medicine, Clinical Municipal Hospital Cluj-Napoca, 400139 Cluj-Napoca, Romania
| | - Alin Grosu
- Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (D.C.); (A.D.); (D.R.); (S.C.); (A.G.); (V.M.); (E.B.); (L.S.); (L.R.); (F.C.); (D.B.J.); (O.M.); (B.M.); (V.D.); (L.M.); (A.M.); (M.R.); (R.C.)
- Department of Internal Medicine, Clinical Municipal Hospital Cluj-Napoca, 400139 Cluj-Napoca, Romania
| | - Valentin Militaru
- Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (D.C.); (A.D.); (D.R.); (S.C.); (A.G.); (V.M.); (E.B.); (L.S.); (L.R.); (F.C.); (D.B.J.); (O.M.); (B.M.); (V.D.); (L.M.); (A.M.); (M.R.); (R.C.)
- Department of Internal Medicine, Clinical Municipal Hospital Cluj-Napoca, 400139 Cluj-Napoca, Romania
| | - Elena Buzdugan
- Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (D.C.); (A.D.); (D.R.); (S.C.); (A.G.); (V.M.); (E.B.); (L.S.); (L.R.); (F.C.); (D.B.J.); (O.M.); (B.M.); (V.D.); (L.M.); (A.M.); (M.R.); (R.C.)
- Department of Internal Medicine, Clinical Municipal Hospital Cluj-Napoca, 400139 Cluj-Napoca, Romania
| | - Laurentiu Stoicescu
- Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (D.C.); (A.D.); (D.R.); (S.C.); (A.G.); (V.M.); (E.B.); (L.S.); (L.R.); (F.C.); (D.B.J.); (O.M.); (B.M.); (V.D.); (L.M.); (A.M.); (M.R.); (R.C.)
- Department of Internal Medicine, Clinical Municipal Hospital Cluj-Napoca, 400139 Cluj-Napoca, Romania
| | - Liliana Radulescu
- Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (D.C.); (A.D.); (D.R.); (S.C.); (A.G.); (V.M.); (E.B.); (L.S.); (L.R.); (F.C.); (D.B.J.); (O.M.); (B.M.); (V.D.); (L.M.); (A.M.); (M.R.); (R.C.)
- Department of Internal Medicine, Clinical Municipal Hospital Cluj-Napoca, 400139 Cluj-Napoca, Romania
| | - Felix Ciovicescu
- Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (D.C.); (A.D.); (D.R.); (S.C.); (A.G.); (V.M.); (E.B.); (L.S.); (L.R.); (F.C.); (D.B.J.); (O.M.); (B.M.); (V.D.); (L.M.); (A.M.); (M.R.); (R.C.)
- Department of Internal Medicine, Clinical Municipal Hospital Cluj-Napoca, 400139 Cluj-Napoca, Romania
| | - Delia Bunea Jivanescu
- Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (D.C.); (A.D.); (D.R.); (S.C.); (A.G.); (V.M.); (E.B.); (L.S.); (L.R.); (F.C.); (D.B.J.); (O.M.); (B.M.); (V.D.); (L.M.); (A.M.); (M.R.); (R.C.)
- Department of Internal Medicine, Clinical Municipal Hospital Cluj-Napoca, 400139 Cluj-Napoca, Romania
| | - Oana Mocan
- Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (D.C.); (A.D.); (D.R.); (S.C.); (A.G.); (V.M.); (E.B.); (L.S.); (L.R.); (F.C.); (D.B.J.); (O.M.); (B.M.); (V.D.); (L.M.); (A.M.); (M.R.); (R.C.)
- Department of Internal Medicine, Clinical Municipal Hospital Cluj-Napoca, 400139 Cluj-Napoca, Romania
| | - Bogdan Micu
- Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (D.C.); (A.D.); (D.R.); (S.C.); (A.G.); (V.M.); (E.B.); (L.S.); (L.R.); (F.C.); (D.B.J.); (O.M.); (B.M.); (V.D.); (L.M.); (A.M.); (M.R.); (R.C.)
- Department of General Surgery, Clinical Municipal Hospital Cluj-Napoca, 400139 Cluj-Napoca, Romania
| | - Valer Donca
- Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (D.C.); (A.D.); (D.R.); (S.C.); (A.G.); (V.M.); (E.B.); (L.S.); (L.R.); (F.C.); (D.B.J.); (O.M.); (B.M.); (V.D.); (L.M.); (A.M.); (M.R.); (R.C.)
- Department of Internal Medicine, Clinical Municipal Hospital Cluj-Napoca, 400139 Cluj-Napoca, Romania
| | - Luminita Marinescu
- Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (D.C.); (A.D.); (D.R.); (S.C.); (A.G.); (V.M.); (E.B.); (L.S.); (L.R.); (F.C.); (D.B.J.); (O.M.); (B.M.); (V.D.); (L.M.); (A.M.); (M.R.); (R.C.)
- Department of Internal Medicine, Clinical Municipal Hospital Cluj-Napoca, 400139 Cluj-Napoca, Romania
| | - Antonia Macarie
- Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (D.C.); (A.D.); (D.R.); (S.C.); (A.G.); (V.M.); (E.B.); (L.S.); (L.R.); (F.C.); (D.B.J.); (O.M.); (B.M.); (V.D.); (L.M.); (A.M.); (M.R.); (R.C.)
- Department of Internal Medicine, Clinical Municipal Hospital Cluj-Napoca, 400139 Cluj-Napoca, Romania
| | - Marina Rosu
- Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (D.C.); (A.D.); (D.R.); (S.C.); (A.G.); (V.M.); (E.B.); (L.S.); (L.R.); (F.C.); (D.B.J.); (O.M.); (B.M.); (V.D.); (L.M.); (A.M.); (M.R.); (R.C.)
- Department of Internal Medicine, Clinical Municipal Hospital Cluj-Napoca, 400139 Cluj-Napoca, Romania
| | - Andrada Nemes
- Intensive Care Unit I, Cluj County Emergency Hospital, 400006 Cluj-Napoca, Romania;
| | - Rares Craciun
- Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400000 Cluj-Napoca, Romania; (D.C.); (A.D.); (D.R.); (S.C.); (A.G.); (V.M.); (E.B.); (L.S.); (L.R.); (F.C.); (D.B.J.); (O.M.); (B.M.); (V.D.); (L.M.); (A.M.); (M.R.); (R.C.)
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18
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Pranata R, Huang I, Lim MA, Yonas E, Vania R, Lukito AA, Nasution SA, Siswanto BB, Kuswardhani RAT. Elevated De Ritis Ratio Is Associated With Poor Prognosis in COVID-19: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2021; 8:676581. [PMID: 35004709 PMCID: PMC8729881 DOI: 10.3389/fmed.2021.676581] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 11/22/2021] [Indexed: 01/08/2023] Open
Abstract
Objective: This meta-analysis aims to assess whether elevated De Ritis ratio is associated with poor prognosis in patients with coronavirus 2019 (COVID-19). Methods: A systematic literature search was performed using PubMed, Embase, and EuropePMC databases up until September 17, 2021. De Ritis ratio is also known as Aspartate aminotransferase/alanine transaminase (AST/ALT) ratio. The main outcome was poor prognosis, a composite of mortality, severity, the need for ICU care, and intubation. The effect measure was odds ratios (ORs) and mean differences. We generated sensitivity and specificity, negative and positive likelihood ratio (NLR and PLR), diagnostic odds ratio (DOR), and area under curve (AUC). Results: There were eight studies with 4,606 patients. De Ritis ratio was elevated in 44% of the patients. Patients with poor prognosis have higher De Ritis ratio [mean difference 0.41 (0.31, 0.50), p < 0.001; I 2: 81.0%] and subgroup analysis showed that non-survivors also have higher De Ritis Ratio [mean difference 0.47 (0.46, 0.48), p < 0.001; I 2: 0%]. Elevated De Ritis ratio was associated with poor prognosis [OR 3.28 (2.39, 4.52), p < 0.001; I 2: 35.8%]. It has a sensitivity of 55% (36-73), specificity of 71% (52-85), PLR 1.9, NLR.63, DOR of 3 (2-4), and AUC of.67 (0.63-0.71). The posterior probability of poor prognosis was 38% if De Ritis is elevated, while 17% if De Ritis is not elevated. Conclusion: Elevated De Ritis ratio is associated with poor prognosis in patients with COVID-19. Systematic Review Registration: PROSPERO ID: CRD42020216634.
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Affiliation(s)
- Raymond Pranata
- Faculty of Medicine, Universitas Pelita Harapan, Tangerang, Indonesia
| | - Ian Huang
- Faculty of Medicine, Universitas Pelita Harapan, Tangerang, Indonesia
- Faculty of Medicine, Department of Internal Medicine, Hasan Sadikin General Hospital, Universitas Padjadjaran, Bandung, Indonesia
| | | | - Emir Yonas
- Faculty of Medicine, Universitas YARSI, Jakarta, Indonesia
| | - Rachel Vania
- Faculty of Medicine, Universitas Pelita Harapan, Tangerang, Indonesia
- Faculty of Medicine, Division of Plastic, Reconstructive, and Aesthetic, Department of Surgery, Sanglah General Hospital, Udayana University, Jimbaran, Indonesia
| | - Antonia Anna Lukito
- Faculty of Medicine, Universitas Pelita Harapan, Tangerang, Indonesia
- Department of Cardiology and Vascular Medicine, Siloam Hospitals Lippo Village, Tangerang, Indonesia
| | - Sally Aman Nasution
- Faculty of Medicine, Division of Cardiology, Department of Internal Medicine, Universitas Indonesia/Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - Bambang Budi Siswanto
- Faculty of Medicine, Department of Cardiology and Vascular Medicine, National Cardiovascular Center Harapan Kita, Universitas Indonesia, Jakarta, Indonesia
| | - Raden A. Tuty Kuswardhani
- Faculty of Medicine, Division of Geriatrics, Department of Internal Medicine, Sanglah Teaching Hospital, Udayana University, Denpasar, Indonesia
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19
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Martha JW. COVID-19 and Cardiovascular Complications: An Updated Review. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.7235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
COVID-19 has become a global pandemic. Patients with pre-existing comorbidities such as hypertension, diabetes, and cardiovascular disease (CVD) are associated with greater severity and higher mortality. COVID-19 can cause cardiovascular complications, including myocardial injury, myocarditis, heart failure, acute coronary syndrome, and coagulation abnormalities. Possible pathophysiology and molecular pathways driving these disease processes are cytokine release syndrome, RAAS system dysregulation, plaque destabilization and coagulation disorders Myocarditis is one concern among persons who received mRNA-Based COVID-19 vaccines. There are several cardiovascular complications that are possibly caused by COVID-19 treatments, such as QT interval prolongation, arrhythmia, and hypotension. Due to increasingly recognized CVD damage in COVID-19, we need to understand about COVID-19 related to cardiovascular complications and treatment strategies.
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20
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Martha JW, Pranata R, Lim MA, Wibowo A, Akbar MR. Active prescription of low-dose aspirin during or prior to hospitalization and mortality in COVID-19: A systematic review and meta-analysis of adjusted effect estimates. Int J Infect Dis 2021; 108:6-12. [PMID: 34000418 PMCID: PMC8123385 DOI: 10.1016/j.ijid.2021.05.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/06/2021] [Accepted: 05/10/2021] [Indexed: 01/08/2023] Open
Abstract
Background This study aimed to investigate whether the active prescription of low-dose aspirin during or prior to hospitalization affects mortality in patients with coronavirus disease 2019 (COVID-19). Aspirin is often prescribed for secondary prevention in patients with cardiovascular disease and other comorbidities that might increase mortality, and may therefore falsely demonstrate increased mortality. To reduce bias, only studies that performed an adjusted analysis were included in this review. Methods A systematic literature search of PubMed, Scopus, Embase and Clinicaltrials.gov was performed, from inception until 16 April 2021. The exposure was active prescription of low-dose aspirin during or prior to hospitalization. The primary outcome was mortality. The pooled adjusted effect estimate was reported as relative risk (RR). Results Six eligible studies were included in this meta-analysis, comprising 13,993 patients. The studies had low-to-moderate risk of bias based on the Newcastle–Ottawa Scale. The meta-analysis indicated that the use of low-dose aspirin was independently associated with reduced mortality {RR 0.46 [95% confidence interval (CI) 0.35–0.61], P < 0.001; I2 = 36.2%}. Subgroup analysis on in-hospital low-dose aspirin administration also showed a significant reduction in mortality [RR 0.39 (95% CI 0.16–0.96), P < 0.001; I2 = 47.0%]. Conclusion Use of low-dose aspirin is independently associated with reduced mortality in patients with COVID-19, with low certainty of evidence.
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Affiliation(s)
- Januar Wibawa Martha
- Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Padjadjaran, Rumah Sakit Umum Pusat Hasan Sadikin, Bandung, Indonesia.
| | - Raymond Pranata
- Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Padjadjaran, Rumah Sakit Umum Pusat Hasan Sadikin, Bandung, Indonesia; Faculty of Medicine, Universitas Pelita Harapan, Tangerang, Indonesia.
| | | | - Arief Wibowo
- Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Padjadjaran, Rumah Sakit Umum Pusat Hasan Sadikin, Bandung, Indonesia.
| | - Mohammad Rizki Akbar
- Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Padjadjaran, Rumah Sakit Umum Pusat Hasan Sadikin, Bandung, Indonesia.
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