FIB-4 score as predictor of COVID-19-related severity in hospitalized patients

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.

Prevention, diagnostic evaluation, management and prognostic implications of liver disease in critically ill patients with COVID-19

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2, broke out in December 2019 in Wuhan city of China and spread rapidly worldwide. Therefore, by March 2020, the World Health Organization declared the disease a global pandemic. Apart from the respiratory system, various other organs of the human body are also seriously affected by the virus. Liver injury in patients with a severe form of COVID-19 is estimated to be 14.8%-53.0%. Elevated levels of total bilirubin, aspartate aminotransferase and alanine aminotransferase and low levels of serum albumin and prealbumin are the main laboratory findings. Patients with pre-existing chronic liver disease and cirrhosis are much more prone to develop severe liver injury. This literature review presented the recent scientific findings regarding the pathophysiological mechanisms responsible for liver injury in critically ill patients with COVID-19, the various interactions between drugs used to treat the disease and the function of the liver and the specific tests providing the possibility of early diagnosis of severe liver injury in these patients. Moreover, it highlighted the burden that COVID-19 put on health systems worldwide and its effect on transplant programs and the care provided to critically ill patients in general and particularly to those with chronic liver disease.

Impact of COVID-19 on Non-Pulmonary Critical Illness: Prevalence, Clinical Manifestations, Management, and Outcomes

Although respiratory manifestations are the most common driver of hospitalization, SARS-CoV-2 infection has a wide range of manifestations, including multisystem organ failure in severe cases. This review discusses the prevalence, pathophysiology, clinical manifestations, treatment, and outcomes of nonpulmonary organ dysfunction from SARS-CoV2, including renal, liver, cardiac, neurologic, and coagulation system dysfunction. At this time, management largely focuses on supportive care practices that are applicable regardless of the cause of organ injury.

Impact of COVID-19 on liver disease: From the experimental to the clinic perspective

Coronavirus disease 2019 (COVID-19) has caused a global pandemic unprecedented in over a century. Although severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a predominantly respiratory infection, various degrees of liver function abnormalities have been reported. Pre-existing liver disease in patients with SARS-CoV-2 infection has not been comprehensively evaluated in most studies, but it can critically compromise survival and trigger hepatic decompensation. The collapse of the healthcare services has negatively impacted the diagnosis, monitoring, and treatment of liver diseases in non-COVID-19 patients. In this review, we aim to discuss the impact of COVID-19 on liver disease from the experimental to the clinic perspective.

A case of COVID 19 with concomitant infection with hepatitis A

Symptoms of COVID-19 range from mild to severe with pulmonary manifestations being predominate, however, liver injury is not rare. There might be a reciprocal influence between COVID-19 and hepatic disease. While high levels of liver enzyme is associated with an increased prevalence of severe complications, search for other etiologies of hepatic disease should be not be ignored. We report a case of COVID-19 presented with acute fulminant hepatitis A (HAV) without previous history.

Abnormal liver biochemistry constitutes an independent prognostic factor of a less favorable clinical course in patients with COVID-19

INTRODUCTION

Abnormal liver biochemistry (ALB) is correlated with increased clinical involvement or severity in COVID-19, but its prognostic implications have not been studied extensively. Our aim is to determine whether ALB is a risk factor for an unfavorable clinical outcome and involvement.

MATERIALS AND METHODS

Retrospective, single-center study of confirmed COVID-19 cases. Patients with pharmacological hepatotoxicity or liver diseases were excluded. ALB was defined as the elevation of total bilirubin, AST, ALT, alkaline phosphatase and/or GGT above the upper limit of normal. An assessment was first made of the correlation between ALB and the need for hospitalization. This was followed by an assessment of the correlation of hospitalized patients with demographic variables, comorbidities and treatment for COVID-19 and with clinical involvement and outcome. Statistical analysis was performed using age-adjusted multiple logistic regression with a p-value of <0.05 RESULTS: Of 1,277 confirmed cases, 346 required hospitalization, and 302 were included. The prevalence of ALB was higher in hospitalized patients compared to non-hospitalized patients (60.9% vs. 10.3%, p ˂0.001). Among the hospitalized patients, there was no correlation between ALB and demographic variables, comorbidities or treatment for COVID-19, except for low molecular weight heparin. We found a significant correlation between ALB and moderate/severe COVID-19 involvement and between unfavorable clinical outcomes and elevated total bilirubin. The period of greatest clinical worsening and deterioration of liver biochemistry parameters occurred during the first seven days. There was a significant correlation between ALB and a longer hospital stay and admission to the Intensive Care Unit, but this did not imply higher mortality.

CONCLUSIONS

ALB is correlated with greater clinical involvement and worse clinical outcomes in hospitalized patients with COVID-19.

Autoimmune hepatitis triggered by COVID-19

We present the case of a 60-year-old woman with no drug allergies or toxic habits, with hypothyroidism and receiving treatment with levothyroxine.

Mild ast elevation as an early sign of COVID-19 severity in a multicenter Madrid cohort

INTRODUCTION

Liver enzyme elevation has been reported for SARS-CoV-2 disease (COVID-19) in heterogeneous cohorts, mainly from China. Comprehensive reports from other countries are needed. We dissect the pattern, evolution and predictive value of such abnormalities in a cohort from Madrid, Spain.

METHODS

Retrospective study with prospective 14-day follow-up of 373 patients with confirmed COVID-19 in five Madrid hospitals, including 50 outpatients. COVID-19 severe course was defined as need of mechanical ventilation.

RESULTS

A total of 33.1% hospitalised patients showed baseline AST elevation and 28.5% showed ALT elevation, contrasting with 12% and 8% of outpatients (P≤0.001). Baseline AST, ALT and GGT levels correlated with LDH and C-reactive protein levels (CRP) (r≤0.598, P<0.005). AST elevation was associated with other severity markers such as male sex, lymphopenia and pneumonia on X-ray (P<0.05 all). ALP and Bilirubin levels were rarely increased. Patients with elevated baseline AST displayed progressive normalization of this enzyme and increase in ALT and GGT levels. Patients with normal baseline AST showed a flattened evolution pattern with levels in range. Patients with a severe course of COVID-19 showed more frequently elevated baseline AST than those with a milder evolution (54.2% vs. 25.4%, P<0.001). Age, AST and CRP were independent risk factors for a severe course of COVID-19.

CONCLUSION

Mild liver enzyme elevation is associated with COVID-19 severity. Baseline AST is an independent predictor of severe COVID-19 course, while it tends to normalize over time. ALT and GGT show late elevation.

COVID-19 and the liver: the chicken or the egg dilemma

After the publication of our meta-analysis, in which we demonstrated that aspartate aminotransferase (AST), alanine aminotransferase (ALT) and total bilirubin were related to a poor prognosis in patients suffering COVID-19, some authors raised the question about whether these findings are directly linked, or they are epiphenomena.

COVID-19 and the digestive system: implications for transforming care delivery

The pandemic caused by SARS-CoV-2 has posed an unprecedented challenge to health systems, leading in many countries to the collapse of health care and a lack of preventive measures both for the most vulnerable sections of the population and among healthcare professionals.