Prevalence and Outcomes Associated with Hyperuricemia in Hospitalized Patients with COVID-19

The predictive significance of uric acid to high density lipoprotein- cholesterol ratio and uric acid for the severity and mortality of coronavirus disease-19

OBJECTIVE

The non-invasive and inexpensive predictive indicators seem to be essential for the evaluation of coronavirus disease-19 (COVID-19) prognosis. Uric acid to high-density lipoprotein-cholesterol ratio (UHR) have been known as inflammatory and metabolic biomarker in some disorders. This study aimed to evaluate the usefulness of serum uric acid (UA) and UHR values on admission as prognostic indicators for the severity and mortality of COVID-19. Regression models were accomplished to assess the association between UA and UHR with the severity and mortality of COVID-19.

RESULTS

This study was performed with 424 confirmed COVID-19 patients. The mean UA and UHR values of the severe group and deceased group were statistically higher than those mild group and survivor group, respectively (P < 0.05). Compared to the survivor cases, deceased subjects had lower serum concentrations of HDL-c (p < 0.05). Multivariate logistic regression analysis showed that UHR and UA values statistically are correlated with the severity (OR = 1.20 CI:1.07-1.35, OR = 1.19 CI:1.023-1.381 respectively) and mortality (OR = 10.04 CI:1.50-67.30, OR = 10.73 CI:1.47-87.11, respectively) of COVID-19. Compared with a reference range, serum UA levels ≥ 7.3 mg/dl and a UHR value greater than 0.185 increase the risk of critical care of COVID-19 almost 2.5 and 3.5 times, respectively. In summary, our results revealed that UHR index value and serum UA levels are useful biochemical indicators for predicting the severity and mortality of COVID-19.

Construction of a nomogram for early diagnosis of refractory Mycoplasma pneumoniae pneumonia in children

Background

Refractory Mycoplasma pneumoniae pneumonia (RMPP) has a serious, rapid progression that can easily cause a variety of extra-pulmonary complications. Therefore, the early identification of RMPP is crucial. This study aimed to construct and validate a risk prediction model based on clinical manifestations, laboratory blood indicators, and radiological findings to help clinicians identify patients who are at high risk of RMPP.

Methods

We retrospectively analyzed the medical records of 369 children with Mycoplasma pneumoniae pneumonia (MPP) admitted to Xi'an Children's Hospital, China. The demographics, clinical features, laboratory data, and radiological findings between the RMPP group and the general Mycoplasma pneumoniae pneumonia (GMPP) group were compared and subjected to univariate and multivariate logistic regression analyses.

Results

The fever peak and duration of the children in the RMPP group (n=86) were higher and longer compared with those in the GMPP group (n=283) (P<0.05). There was a significant difference in the incidence of lobar pneumonia and pleural effusion in pulmonary imaging between the two groups (P<0.05). Laboratory tests showed that the children with RMPP had lower serum uric acid (SUA) and albumin (ALB) as compared with the GMPP group (P<0.05). White blood cells (WBCs), neutrophil count (NEP), erythrocyte sedimentation rate (ESR), procalcitonin (PCT), C-reactive protein (CRP), and neutrophil-to-lymphocyte ratio (NLR) were higher in the RMPP group (P<0.05). Binary logistic regression analysis showed that the fever duration, pleural effusion, WBC, NEP, lactate dehydrogenase (LDH), CRP, NLR, and SUA levels were independent predictors of RMPP (P<0.05). The receiver operator characteristic (ROC) curve results showed fever duration, WBC, NEP, CRP, LDH, SUA, and NLR had good predictive value. The areas under the curve (AUCs) were 0.861, 0.730, 0.758, 0.837, 0.868, 0.744, and 0.713 and the best cutoff values were 10.50, 10.13, 6.43, 29.45, 370.50, 170.50, and 3.47, respectively. Finally, fever duration of more than 10.5 days, pleural effusion, WBC >10.13×109/L, NEP >6.43×109/L, CRP >29.45 mg/L, LDH >370.50 U/L, NLR >3.47, and SUA <170.5 µmol/mL constructed a prediction model of RMPP. According to internal validation, the mean AUC of the nomogram based on the development dataset was 0.956 [95% confidence interval (CI): 0.937-0.974] with good discrimination ability for predicting RMPP patients. The calibration plot and Hosmer-Lemeshow test (P=0.70) of the prediction model showed good consistency between the predicted probability and actual probability. Decision curve analysis (DCA) showed that the nomogram is clinically useful.

Conclusions

The simple and easy-to-use nomogram can help clinicians, especially primary doctors, to make early diagnoses of RMPP.

Heterogeneity in the definition of major adverse kidney events: a scoping review

Acute kidney injury (AKI) is associated with persistent renal dysfunction, the receipt of dialysis, dialysis dependence, and mortality. Accordingly, the concept of major adverse kidney events (MAKE) has been adopted as an endpoint for assessing the impact of AKI. However, applied criteria or observation periods for operationalizing MAKE appear to vary across studies. To evaluate this heterogeneity for MAKE evaluation, we performed a systematic scoping review of studies that employed MAKE as an AKI endpoint. Four major academic databases were searched, and we identified 122 studies with increasing numbers over time. We found marked heterogeneity in applied criteria and observation periods for MAKE across these studies, with some even lacking a description of criteria. Moreover, 13 different observation periods were employed, with 30 days and 90 days as the most common. Persistent renal dysfunction was evaluated by estimated glomerular filtration rate (34%) or serum creatinine concentration (48%); however, 37 different definitions for this component were employed in terms of parameters, cut-off criteria, and assessment periods. The definition for the dialysis component also showed significant heterogeneity regarding assessment periods and duration of dialysis requirement (chronic vs temporary). Finally, MAKE rates could vary by 7% [interquartile range: 1.7-16.7%] with different observation periods or by 36.4% with different dialysis component definitions. Our findings revealed marked heterogeneity in MAKE definitions, particularly regarding component assessment and observation periods. Dedicated discussion is needed to establish uniform and acceptable standards to operationalize MAKE in terms of selection and applied criteria of components, observation period, and reporting criteria for future trials on AKI and related conditions.

Serum uric acid levels in kidney transplant recipients: A cause for concern? A review of recent literature

The impact of elevated serum uric acid levels i.e., hyperuricemia, on native and transplant chronic kidney disease progression has been debated. This literature review presents an analysis of multiple studies exploring the relationship between serum uric acid levels and kidney transplant outcomes. The review includes a summary of the pathophysiology of hyperuricemia and gout, a review of urate-lowering therapies, and an appraisal of multiple studies examining the association or lack thereof between serum uric acid level and kidney transplant outcomes. Based on these studies, elevated serum uric acid levels may contribute to CKD progression in kidney transplant recipients. In this review, we also summarize current literature to highlight risk factors associated with hyperuricemia as well as the need for further investigation to monitor and manage hyperuricemia in kidney transplant recipients.

Propensity-Score Matched Analysis of the Effectiveness of Baricitinib in Patients With Coronavirus Disease 2019 (COVID-19) Using Nationwide Real-World Data: An Observational Matched Cohort Study From the Japan COVID-19 Task Force

Background

To determine the effectiveness of baricitinib in patients with coronavirus disease 2019 (COVID-19), investigate whether baricitinib prevents the need for invasive mechanical ventilation and identify patient subgroups that would benefit from baricitinib.

Methods

This observational matched-cohort study was conducted by the Japan COVID-19 Task Force, a nationwide multicenter consortium. Patients with COVID-19 aged ≥18 years were identified from 70 hospitals in Japan. Among patients with confirmed COVID-19 from February 2020 to September 2021, those receiving baricitinib were propensity-score matched with controls.

Results

Among 3309 patients, 144 propensity score-matched pairs were identified. Thirteen (9.0%) patients in the baricitinib group and 27 (18.8%) in the control group required invasive mechanical ventilation during the disease course (odds ratio, 0.43). Although the baricitinib group had more severe disease, there were no significant differences in the intensive care unit admission rates (odds ratio, 1.16) and mortality rates (odds ratio, 0.74) between groups. In subgroup analyses, baricitinib was associated with a significant reduction in the need for invasive mechanical ventilation in patients requiring oxygen support (odds ratio, 0.28), with rapid shadow spread on chest radiography (odds ratio, 0.11), or treated with remdesivir (odds ratio, 0.27), systemic corticosteroids (odds ratio, 0.31), or anticoagulants (odds ratio, 0.17).

Conclusions

Baricitinib is effective at preventing the need for invasive mechanical ventilation in patients with COVID-19.

Asymptomatic hyperuricaemia in chronic kidney disease: mechanisms and clinical implications

Asymptomatic hyperuricaemia (HU) is considered a pathogenic factor in multiple disease contexts, but a causative role is only proven for the crystalline form of uric acid in gouty arthritis and urate nephropathy. Epidemiological studies document a robust association of HU with hypertension, cardiovascular disease (CVD) and CKD progression, but CKD-related impaired uric acid (UA) clearance and the use of diuretics that further impair UA clearance likely accounts for these associations. Interpreting the available trial evidence is further complicated by referring to xanthine oxidase inhibitors as urate-lowering treatment, although these drugs inhibit other substrates, so attributing their effects only to HU is problematic. In this review we provide new mechanistic insights into the biological effects of soluble and crystalline UA and discuss clinical evidence on the role of asymptomatic HU in CKD, CVD and sterile inflammation. We identify research areas with gaps in experimental and clinical evidence, specifically on infectious complications that represent the second common cause of death in CKD patients, referred to as secondary immunodeficiency related to kidney disease. In addition, we address potential therapeutic approaches on how and when to treat asymptomatic HU in patients with kidney disease and where further interventional studies are required.

Factors Contributing to Chronic Kidney Disease following COVID-19 Diagnosis in Pre-Vaccinated Hospitalized Patients

In this study, we aim to evaluate the factors that may contribute to the development of chronic kidney disease following COVID-19 infection among hospitalized patients in two private hospitals in Jakarta, Indonesia. This is a retrospective cohort study between March 2020 and September 2021. Patient selection was conducted with a convenience sampling. All patients (n = 378) meeting the inclusion criteria during the study period were enrolled. Various sociodemographic, laboratory test, and diagnostic parameters were measured before the determination of their correlation with the outcome of COVID-19 infection. In this study, all pre-vaccinated patients with COVID-19 had no history of chronic kidney disease (CKD) prior to hospital admission. From this number, approximately 75.7% of the patients developed CKD following COVID-19 diagnosis. Overall, significant correlations were established between the clinical outcome and the CKD status (p = 0.001). Interestingly, there was a significant correlation between serum creatinine level, glomerular filtration rate (GFR), and CKD (p < 0.0001). Oxygen saturation (p = 0.03), admission to the intensive care unit (ICU) (p < 0.0001), and sepsis (p = 0.005) were factors that were significantly correlated with CKD status. Additionally, the type of antibiotic agent used was significantly correlated with CKD (p = 0.011). While 82.1% of patients with CKD survived, the survival rate worsened if the patients had complications from hyperuricemia (p = 0.010). The patients who received levofloxacin and ceftriaxone had the highest (100%) survival rate after approximately 50 days of treatment. The patients who received the antiviral agent combination isoprinosine + oseltamivir + ivermectin fared better (100%) as compared to those who received isoprinosine + favipiravir (8%). Factors, such as hyperuricemia and the antibiotic agent used, contributed to CKD following COVID-19 hospitalization. Interestingly, the patients who received levofloxacin + ceftriaxone and the patients without sepsis fared the best. Overall, patients who develop CKD following COVID-19 hospitalization have a low survival rate.

Redox imbalance in COVID-19 pathophysiology

Background

The pathophysiologic significance of redox imbalance is unquestionable as numerous reports and topic reviews indicate alterations in redox parameters during corona virus disease 2019 (COVID-19). However, a more comprehensive understanding of redox-related parameters in the context of COVID-19-mediated inflammation and pathophysiology is required.

Methods

COVID-19 subjects (n = 64) and control subjects (n = 19) were enrolled, and blood was drawn within 72 h of diagnosis. Serum multiplex assays and peripheral blood mRNA sequencing was performed. Oxidant/free radical (electron paramagnetic resonance (EPR) spectroscopy, nitrite-nitrate assay) and antioxidant (ferrous reducing ability of serum assay and high-performance liquid chromatography) were performed. Multivariate analyses were performed to evaluate potential of indicated parameters to predict clinical outcome.

Results

Significantly greater levels of multiple inflammatory and vascular markers were quantified in the subjects admitted to the ICU compared to non-ICU subjects. Gene set enrichment analyses indicated significant enhancement of oxidant related pathways and biochemical assays confirmed a significant increase in free radical production and uric acid reduction in COVID-19 subjects. Multivariate analyses confirmed a positive association between serum levels of VCAM-1, ICAM-1 and a negative association between the abundance of one electron oxidants (detected by ascorbate radical formation) and mortality in COVID subjects while IL-17c and TSLP levels predicted need for intensive care in COVID-19 subjects.

Conclusion

Herein we demonstrate a significant redox imbalance during COVID-19 infection affirming the potential for manipulation of oxidative stress pathways as a new therapeutic strategy COVID-19. However, further work is requisite for detailed identification of oxidants (O₂^•-, H₂O₂ and/or circulating transition metals such as Fe or Cu) contributing to this imbalance to avoid the repetition of failures using non-specific antioxidant supplementation.

Clinical clustering with prognostic implications in Japanese COVID-19 patients: report from Japan COVID-19 Task Force, a nation-wide consortium to investigate COVID-19 host genetics

Background

The clinical course of coronavirus disease (COVID-19) is diverse, and the usefulness of phenotyping in predicting the severity or prognosis of the disease has been demonstrated overseas. This study aimed to investigate clinically meaningful phenotypes in Japanese COVID-19 patients using cluster analysis.

Methods

From April 2020 to May 2021, data from inpatients aged ≥ 18 years diagnosed with COVID-19 and who agreed to participate in the study were collected. A total of 1322 Japanese patients were included. Hierarchical cluster analysis was performed using variables reported to be associated with COVID-19 severity or prognosis, namely, age, sex, obesity, smoking history, hypertension, diabetes mellitus, malignancy, chronic obstructive pulmonary disease, hyperuricemia, cardiovascular disease, chronic liver disease, and chronic kidney disease.

Results

Participants were divided into four clusters: Cluster 1, young healthy (n = 266, 20.1%); Cluster 2, middle-aged (n = 245, 18.5%); Cluster 3, middle-aged obese (n = 435, 32.9%); and Cluster 4, elderly (n = 376, 28.4%). In Clusters 3 and 4, sore throat, dysosmia, and dysgeusia tended to be less frequent, while shortness of breath was more frequent. Serum lactate dehydrogenase, ferritin, KL-6, d-dimer, and C-reactive protein levels tended to be higher in Clusters 3 and 4. Although Cluster 3 had a similar age as Cluster 2, it tended to have poorer outcomes. Both Clusters 3 and 4 tended to exhibit higher rates of oxygen supplementation, intensive care unit admission, and mechanical ventilation, but the mortality rate tended to be lower in Cluster 3.

Conclusions

We have successfully performed the first phenotyping of COVID-19 patients in Japan, which is clinically useful in predicting important outcomes, despite the simplicity of the cluster analysis method that does not use complex variables.