key: cord-0685155-61gtx2h2
authors: Lopez-Mendez, Ivan; Aquino-Matus, Jorge; Gall, Sofia Murua-Beltrán; Prieto-Nava, Jose D.; Juarez-Hernandez, Eva; Uribe, Misael; Castro-Narro, Graciela
title: Association of liver steatosis and fibrosis with clinical outcomes in patients with SARS-CoV-2 infection (COVID-19)
date: 2020-10-21
journal: Ann Hepatol
DOI: 10.1016/j.aohep.2020.09.015
sha: d7ed1464073b1dee8394617957b921bcfaadabf4
doc_id: 685155
cord_uid: 61gtx2h2

INTRODUCTION AND OBJECTIVES: Liver function tests (LFT) abnormalities are reported in up to 50% of COVID-19 patients, metabolic comorbidities are associated with poorer outcomes. The aim of the study is to determine prevalence of liver steatosis and fibrosis in patients with COVID-19 and their association with clinical outcomes. MATERIAL AND METHODS: Retrospective study in hospitalized COVID-19 patients. Risk for liver steatosis was estimated by HSI > 36, and risk for advanced liver fibrosis with APRI > 1.0, NAFLD FS > 0.675 and/or FIB-4 > 3.25. Clinical outcomes were admission to Intensive Care Unit (ICU) and mortality. RESULTS: Of 155 patients, 71.6% were male (n = 111), and 28.4% (n = 44) were obese. Abnormal LFT were present in 96.8% (n = 150), prevalence of steatosis was 42.6% (n = 66) and of significative liver fibrosis was 44.5% (n = 69). Liver fibrosis by FIB-4 was associated with risk of ICU admission (OR 1.74 [95%CI 1.74-2.68; p = 0.023]) and mortality (OR 6.45 [95%CI 2.01-20.83, p = 0.002]), no independent associations were found. CONCLUSIONS: The prevalence of steatosis and significant liver fibrosis was high in COVID-19 patients but was not associated with clinical outcomes.

The novel Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) virus emerged in Wuhan, China, in December 2019; it is a highly transmittable pathogen that causes the coronavirus disease 19 . The two previous betacoronavirus epidemics of global concern where the Severe Acute Respiratory Syndrome coronavirus (SARS-CoV) The Centers for Disease Control and Prevention (CDC) revised and updated a summary of medical conditions associated with increased risk of severe illness derived from COVID-19, which included among others, obesity (body mass index (BMI) >30 kg/m 2 ) and Type 2 Diabetes Mellitus (T2DM). In Mexico, 72.5% of the adult population is overweight and 9.4% have T2DM(4) Additionally, the prevalence of hepatic steatosis in Mexico ranges from 14 .4% to 62.9%, (5) and he prevalence of liver fibrosis has been reported in 8.1% (noninvasive assessment).(6) Currently, Mexico City is one of the most affected regions in the world with rising numbers of cases and deaths caused by COVID-19, and we have very few data regarding GI symptoms and LFT abnormalities and their prognostic value in Mexican patients.

J o u r n a l P r e -p r o o f

We conducted a retrospective, cross sectional, descriptive study using electronic medical records of adult patients (>18 years old) with a positive RT-PCR SARS-CoV-2 test (GeneFinder TM COVID-19 PLUS RealAmp Kit, OSANG Healthcare Co., Ltd. Korea) in nasopharyngeal swab, admitted to Medica Sur Clinic & Foundation between March 14 th through June 5 th , 2020. Patients with COVID-19 diagnosis but without LFT determination in the first 48 hours after admission were excluded. Clinical and biochemical data were included in the analysis. The study was approved by the Medica Sur Ethics Committee (2020-EXT-487).

The presence of steatosis was determined by Hepatic Steatosis Index (HSI) by the formula 8 

The distribution of data was assessed by the Kolmogorov-Smirnov test. Continuous data were presented as median an interquartile range; categorical data were presented as percentage and frequencies. The Mann-Whitney U test was used to evaluate differences between patients with and without steatosis, as well as liver fibrosis. The association of categorical data and clinical outcomes was analyzed by Chi square. Univariate and multivariate analyses were performed for associations between steatosis and liver fibrosis with Intensive Care Unit J o u r n a l P r e -p r o o f (ICU) admission and mortality. The p-values <0.05 were considered statistically significant.

SPSS v.21 was used for statistical analysis.

A total of 155 patients were included in the final analysis, from which 71.6% (n=111) were male; median of age and BMI were 51 [42-62] years and 27.9 [25.8-30.5 ] kg/m 2 , respectively. Obesity (28.4%, n=44), hypertension (23.2%, n=36), and T2DM (15.5%, n=24)

were the most frequent comorbidities. Only 2 patients (1.3%) reported a preexisting liver disease. Among biochemical parameters, the median of hemoglobin was 14.8 [13.7-15.9] g/dL, platelets 198 [162-254] x 10 9 /L, and leukocytes 7.1 [5.3-9.9] x 10 9 /L. Demographic data, clinical characteristics, drug history, and biochemical parameters are shown in Table 1 .

Patients had a median of 7 [5] [6] [7] [8] [9] [10] days with symptoms before admission, which included fever in 69.7% (n=108), cough in 65.2% (n=101), and dyspnea in 47.7% (n=74). Median of hospital stay was 9 [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] days and 34.2% (n=53) of the patients required admission to the ICU, with a median stay of 13 [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] days.

At least one GI symptom was reported in 36.1% (n=56) of the patients, which included diarrhea in 25.8% (n=40), nausea in 9% (n=14), and anorexia in 9% (n=14). Regarding LFT (Table 2 ), a total of 96.8% (n=150) of patients presented at least one abnormality, and lactate dehydrogenase was the most frequent in 89.7% (n=139) of the cases.

The prevalence of steatosis by HSI score >36 was 42.6% (n=66) and it was not associated with clinical outcomes. On the other hand, the prevalence of advanced liver fibrosis by any model was 44.5% (n=69), which is shown in Figure 1 . The prevalence of T2DM was higher among patients with fibrosis (66.7% (n=16) vs. 33.3% (n=8), p=0.025), and mortality was also higher in these patients (81.8% (n=9) vs. 18.2% (n=2), p=0.012); however, no independent associations were found in multivariate analyses.

Differences in basal biochemical levels were found in patients with advanced liver fibrosis. Mortality was 7.1% (n=11) and the associated factors were hypertension, basal total bilirubin, basal direct bilirubin, and liver fibrosis by any method, as well as by NAFLD FS and FIB-4;

( 

As expected, due to the epidemiological context of Mexico, in our study we found a high prevalence of metabolic comorbidities which included obesity, hypertension, and T2DM, which were associated with clinical outcomes in univariate analyses. Obese patients face an increased risk for severe complications and mortality. They also represent a challenge for therapeutic maneuvers such as imaging diagnosis, intubation, mechanical ventilation, and pronation, among others.(11) A meta-analysis including 3,207 patients with COVID-19 described that underlying chronic conditions such as hypertension, diabetes, and cardiovascular and respiratory diseases were higher in critical/non-surviving patients; clinical manifestations such as fever and dyspnea were also associated with the progression of the disease.(12) We found similar results in our study, with dyspnea as the most important associated symptom for ICU admission with OR 4.07 (CI95% 1.6-9.86).

The pathogenesis of GI symptoms and liver injury in COVID-19 is still a subject of research. Although ACE2 is not expressed in Kupffer cells, hepatocytes, and endothelium of liver sinusoids,(15) expression of ACE2 is induced by hypoxia in cultured hepatocytes (17) and it has been shown that COVID-19 infection is associated with liver disease, ranging from a mild to severe damage, but it is usually transient.(2) Currently, there is no consensus on the exact mechanism of liver injury, but it may be related to: 1) direct cytopathic damage, 2) systemic inflammatory response, 3) liver hypoxia and ischemia, 4) acute-on-chronic liver injury, or 5) drug-induced liver injury. (18) It has been recently demonstrated the presence of SARS-CoV-2 virions inside hepatocytes (19) and that death of cholangiocytes induced by SARS-CoV-2.(20) Even though it has not been demonstrated in humans, hepatic steatosis in mice models increases hepatic ACE2 mRNA (21) , which could explain, at least in theory, the relationship between SARS-CoV-2 and liver injury in MAFLD patients. The liver harvests a great pool of macrophages and immune cells, that in addition to a particular susceptibility of hepatocytes to proinflammatory cytokines, the systemic inflammatory response can easily produce liver injury as a collateral damage. (19) The global prevalence of GI symptoms in COVID-19 patients has been reported between 11.3% and 79.1%. (22) In our study, GI symptoms were reported in 36.1% (n=56), which is similar to another recent Mexican study which reported a prevalence of 20.8%. (23) Additionally, a meta-analysis which included 6,686 patients estimated that 15% of them had at least one GI symptom and that 10% only had GI symptoms upon presentation.(24) Another systematic review and meta-analysis which included 12,797 patients reported that mortality in the group of patients with GI symptoms (0.4% [IC95%, 0-1.1%; I 2 =74%]) was similar (p=0.15) to overall mortality (2.1% [IC95%, 0.2-4.7%; I 2 =94%]). (25) Abnormal LFT were found in 96.8% (n=150) of our patients, which is higher that recent studies reporting a prevalence ranging from 16.1% to 76.3%, (3, 26) including 21.5% of liver injury prevalence during hospitalization.(3) Our study did not find an association between abnormal LFT and mortality, as a multicentric study in China that included 5,771 patients which found that abnormal AST was associated with increased mortality risk by any cause with an OR 4.81 (IC95%, 3.38-6.86; p<0.001), which increased to OR 14.87 (IC95%, 9.64-22.93; p<0.001) in the group with AST above 120 IU/L (27) .

We described a prevalence of 42.6% (n=66) of steatosis, which was not associated with clinical outcomes. In contrast, a retrospective study (28) 

J o u r n a l P r e -p r o o f found a prevalence of MAFLD of 37.6% and higher risk of disease progression. Since MAFLD is currently considered the liver manifestation of metabolic syndrome (29) these patients are considered chronically inflamed and this fact could contribute to the interplay in the cytokine storm described in COVID-19, resulting in the progression of the disease, its complications, and fatal outcomes. (30) This explanation is supported by Zheng et al's study (31) in China, in which 30% of the patients presented MAFLD, according to tomographic criteria, and found an increased 6-fold risk of severe COVID-19 and obesity in MAFLD patients, in comparison to non-obese patients (OR 6.32, 95%CI 1.16-34.54, p=0.033). The addition of metabolic comorbidities may increase the risk of serious complications in this group of patients, but further research is required.

In our study, we found a pooled prevalence of advanced liver fibrosis of 44.5% (n=69) through any non-invasive liver assessment model, which was associated with hospital outcomes. This result is in concordance to the multicenter study by Ibáñez-Samaniego et al. (32) in Spain, which included 160 patients and estimated a risk for advanced fibrosis in 28.1%. A FIB-4 ≥2.67 score increased the risk of ICU admission as an independent risk factor (OR 3.41, 95%CI 1. 30-8.92 ). Interestingly, in the multivariate analysis with exclusion of patients with MAFLD, FIB-4≥2.67 remained as a risk factor for mechanical ventilation (OR 3.25; 95% CI, 1.24-8.53). In our study, no independent associations were found for liver fibrosis and clinical outcomes.

These associations are interesting but must be interpreted with caution, since most of the noninvasive predictive models include variables that may be affected by the COVID-19 infection as well, resulting in overdiagnosis of liver fibrosis upon presentation. Nonetheless, we consider that screening for liver fibrosis in patients with COVID-19 would contribute to further risk stratification and to design follow-up strategies in surviving patients who were unaware of their liver diseases, especially in regions where obesity and other metabolic comorbidities are highly prevalent.

Our study only included two patients with preexisting chronic liver disease, but a previous report by an International Registry (COVID-Hep.net and COVIDCirrhosis.org) that included 152 patients showed that 23.3% were admitted to the ICU and 17.5% required mechanical ventilation, with a reported mortality of 39.8%. (33) A meta-analysis with 1,558 patients from reported important associations between MAFLD and COVID-19 severity. In a retrospective study of 202 patients in China, MAFLD was associated with COVID-19 progression had (OR 6.4; 95% IC, 1.5-31.2). (36) Further research, especially in the Americas, is required to elucidate the relationship between liver disease and COVID-19 regarding clinical outcomes.

Limitations of our study include the retrospective design, the assessment of liver fibrosis through non-invasive models, and the conduction of the study in a private hospital; additionally, as this is not a prospective design, decisions in management and timing of laboratory tests are based on each attending physician during hospital course.

In COVID-19 patients, the prevalence of liver steatosis and advanced liver fibrosis by noninvasive assessment prediction models was high and was not associated with clinical outcomes; 96.8% of COVID-19 patients had at least one abnormal LFT. The presence of metabolic comorbidities was associated with mortality and ICU admission. The timely diagnosis of COVID-19 patients, including those presenting GI symptoms and abnormal LFT, is of utmost importance in the fight towards reducing mortality.

J o u r n a l P r e -p r o o f 

Clinical features of patients infected with 2019 novel coronavirus in Wuhan

Gastrointestinal, hepatobiliary, and pancreatic manifestations of COVID-19

COVID-19: Abnormal liver function tests

Obesity and public health in Mexico: Transforming the hegemonic food supply and demand pattern

The Mexican consensus on nonalcoholic fatty liver disease

Prevalence of liver fibrosis in an unselected general population with high prevalence of obesity and diabetes mellitus. Time for screening?

Hepatic steatosis index: A simple screening tool reflecting nonalcoholic fatty liver disease. Dig Liver Dis

Performance of the aspartate aminotransferase-to-platelet ratio index for the staging of hepatitis C-related fibrosis: An updated meta-analysis

The NAFLD fibrosis score: A noninvasive system that identifies liver fibrosis in patients with NAFLD

Development of a simple noninvasive index to predict significant fibrosis in patients with HIV/HCV coinfection

COVID-19 infection: Origin, transmission, and characteristics of human coronaviruses

A new coronavirus associated with human respiratory disease in China

Tissue distribution of ACE2 protein, the functional receptor for SARS coronavirus. A first step in understanding SARS pathogenesis

Review article: gastrointestinal features in COVID-19 and the possibility of faecal transmission

Chronic liver injury in rats and humans upregulates the novel enzyme angiotensin converting enzyme 2

What Has the COVID-19 Pandemic Taught Us so Far? Addressing the Problem from a Hepatologist's Perspective

Direct or Collateral Liver Damage in SARS-CoV-2-Infected Patients

Recapitulation of SARS-CoV-2 infection and cholangiocyte damage with human liver ductal organoids

Pioglitazone upregulates hepatic angiotensin converting enzyme 2 expression in rats with steatohepatitis

Beware: Gastrointestinal symptoms can be a manifestation of COVID-19

Solís-gonzález A. Initial Gastrointestinal Manifestations in Patients with SARS-CoV-2 in 112 patients from Veracruz

Manifestations and prognosis of gastrointestinal and liver involvement in patients with COVID-19: a systematic review and meta-analysis

Prevalence and Mortality of COVID-19 patients with Gastrointestinal Symptoms: A Systematic Review and Metaanalysis

Liver injury in COVID-19: management and challenges

Longitudinal association between markers of liver injury and mortality in COVID-19 in China

Non-alcoholic fatty liver diseases in patients with COVID-19: A retrospective study

A new definition for metabolic dysfunction-associated fatty liver disease: An international expert consensus statement

COVID-19 and nonalcoholic fatty liver disease: two intersecting pandemics

Letter to the Editor: Obesity as a risk factor for greater severity of COVID-19 in patients with metabolic associated fatty liver disease

Elevation of liver fibrosis index FIB-4 is associated with poor clinical outcomes in patients with COVID-19

High Mortality Rates for SARS-CoV-2 Infection in Patients with Pre-existing Chronic Liver Disease and Cirrhosis: Preliminary Results from an International Registry

Does comorbidity increase the risk of patients with covid-19: Evidence from meta-analysis

Clinical Characteristics and Outcomes of Coronavirus Disease

Among Patients With Preexisting Liver Disease in the United States: A Multicenter Research Network Study

Non-alcoholic fatty liver diseases in patients with COVID-19: A retrospective study