key: cord-0873297-g1kvl51c
authors: Hu, Xingzhong; Chen, Dong; Wu, Lianpeng; He, Guiqing; Ye, Wei
title: Declined serum high density lipoprotein cholesterol is associated with the severity of COVID-19 infection
date: 2020-07-10
journal: Clin Chim Acta
DOI: 10.1016/j.cca.2020.07.015
sha: 8ce6c6404c2f97fbec732ca762b948d802989ac1
doc_id: 873297
cord_uid: g1kvl51c

BACKGROUND: COVID-19 infection is epidemic worldwide. We describe the serum lipid profile of the patients with COVID-19 infection. METHODS: In this retrospective study, we collected the first clinical laboratory data of 114 patients on admission, and 80 healthy controls. Meanwhile, we monitored the serum lipid profile, COVID-19 nucleic acid and chest CT scan of a severe patient from the early stage of infection to the recovery period for a total of 80 days. RESULTS: Compared with the healthy controls, the patients had sharply decreased concentrations of total cholesterol, HDL-cholesterol and LDL-cholesterol (P<0.001). Among the patients, HDL-cholesterol concentration in severe groups was significantly lower than the common groups [1.01 (0.88-1.20) vs 1.21 (1.02-1.48) mmol/l, P<0.001]. The lipid profile of a severe patient showed that serum cholesterol concentration significantly decreased in the early stage and returned to be normal in the recovery period. Moreover, the change of HDL-cholesterol in this patient was consistent with the results of nucleic acid tests and chest CT scans. In correlation analysis, HDL-cholesterol concentration was negatively correlated with C-reactive protein (CRP, r=-0.396, P<0.001) and positively correlated with lymphocytes (r=0.336, P<0.001). The area under curve (AUC) in receiver operating characteristic (ROC) of HDL-cholesterol was 0.732 (P<0.001), and, the adjusted odd ratio (OR) of HDL-cholesterol was 0.023 (95% CI 0.002-0.227). CONCLUSIONS: Decreased serum HDL-cholesterol is associated with the severity of COVID-19 infection.

examination showed that the bilateral pneumonia, and multiple mottling and groundglass opacity. Laboratory tests detection indicated that declined white blood cells and lymphocytes concentration in the patients [1, 2] . 5 The altered serum lipid concentrations, especially cholesterol concentration, have been reported to occur during infection with viruses including human immunodeficiency virus (HIV) and hepatitis C virus (HCV). Some proteins, such as scavenger receptor class B type I (SR-BI), a major receptor of high-density lipoprotein (HDL) and play a crucial role in cholesterol homeostasis, were indicated to involve in HCV infection [3] . Moreover, membrane cholesterol has been indicated to be important component for the entering into host cells of pathogenic viruses [4] .

We recruited 114 COVID-19-infected patients from Jan 2 nd to Feb 20 th at Wenzhou Central Hospital, in Wenzhou, China. All cases were diagnosed according to the positive result of viral nucleic acid assay by a real-time reverse transcriptionpolymerase chain reaction (RT-PCR) assay (Bio-germ) in testing respiratory specimens. To avoid the interference of antiviral treatment on the serum lipid concentrations, we collected the first laboratory results of patients on admission, all of which were untreated at that time. The common or severe cases were diagnosed according to the Novel Coronavirus Pneumonia Diagnosis and Treatment Intern Guidance (the 7 th revised version) [5] .

For comparative study, we also recruited 80 age-matched healthy controls in healthy center of Wenzhou Central Hospital, excluding the subjects with dyslipidemia, diabetes, cardiovascular diseases and hypertension. All of the health 6 controls had the negative results in the COVID-19 nucleic acid tests. Our study was authorized by Ethics Commission of Wenzhou central hospital(No. L2020-01-003).

To investigate the relationship between lipid profile and severity of COVID-19 infection, we continuously monitored the serum biochemical indexes, blood cell counting, COVID-19 nucleic acid from sputum and chest CT imaging examination of a severe case with interferon-a inhalation treatment from day 1 to day 16 on admission, and additionally measured the indexes on day 30, day 45, and day 80 when she was cured.

For detecting serum lipid concentration, blood samples were collected from each subject after at least 12 hours of overnight fasting. For avoiding the interference of treatment to serum lipid concentration, the first laboratory data on admission were collected for our study. Hematological parameters were analyzed on BC-5380 automatic blood cells analyzer. Biochemical parameters were performed on AU5800 chemistry analyzer. All laboratory assays had completed the standardization and certification program.

Continuous variables were expressed as median (IQR) and analyzed with Mann-Whitney U test; categorical variables were expressed as number (%) and compared by 7 χ² test between patients and controls groups, or between common group and severe group of patients. The associations between serum HDL-cholesterol and severe COVID-19 infection were determined using binary logistic regression model.

Bivariate correlation analysis (Pearson correlation) was performed for analyzing the correlation of serum lipid concentration and other laboratory parameters. A p<0.05 was considered statistically significant. Statistical analyses were performed using the SPSS 17.0 statistical package and GraphPad Prime 6. (Table 1) .

For investigating the relationship between serum lipid and severity of infection, firstly the cases were divided into common group and severe group. As the data showed in Table 2 , the average age of the 27 severe patients was 62 y, significantly in this process (Fig. 2 E) , however, the curves of serum triglyceride and CRP indicated the significant instability of changes (Fig. 2 D, F) .

Meanwhile, the COVID-19 nucleic acid tests showed the positive results from the day 1 to day 6 on admission. Since then, all of the nucleic acid tests were negative 9 (Fig. 3 A) . The imaginations of the chest CT scan showed the multiple mottling and ground-glass opacity of the both lung in the early stages of the infection, and then turned to be normal as the disease recovered (Fig. 3 B) .

Receiver operating characteristic (ROC) analysis was performed to evaluate the ability of serum HDL-cholesterol to predict the severity of COVID-19 infection. As ROC curve showed, AUC was 0.732 (Fig. 4, P<0.001) . In further analysis, odd ratio (OR) firstly was used to evaluate the association of serum lipid in COVID-19

infection. Only HDL-cholesterol [adjusted OR 0.023, 95% CI (0.002-0.227)] was independently associated with sever COVID-19 infection (Table 3 , P<0.001).

In this study, we collected 114 COVID-19-infected patients, including 87 common cases and 27 severe cases, and 80 age-matched heathy controls. Our findings indicated significantly dyslipidemia in COVID-19-infected patients. The characteristics of serum lipid profile of COVID-19-infected patients presented declined concentration of total cholesterol, HDL-cholesterol and LDL-cholesterol (Table 1 ). More notably, the severe cases showed significantly lower concentration of HDL-cholesterol than the common cases ( Table 2) .Those results are similar to the data in recent clinical studies [6, 7] .

Further, the correlation between HDL-cholesterol and infection progression was explored. CRP is commonly recognized and sensitive biomarker of inflammation. The result showed that HDL-cholesterol concentration was negatively related with CRP concentration. The correlation between CRP and HDL-cholesterol had been discussed in the two prospective population-based cohort studies previously. The data in the study showed that the individuals with HDL cholesterol below 0.8mmol/l (31mg/dL), CRP was 1.8 (1.2-3.2) and 2.4 (1.5-4.8) mg/l respectively [8] , which also indicated that the negatively relationship between HDL-cholesterol and CRP. Moreover, the emerging events recently suggested that the increased CRP concentration was an accurate indicator in predicting COVID-19 infection [9, 10] . Our result is consistent with these findings. In addition, we found HDL-cholesterol concentration was positively correlated with lymphocytes count. In the previous reports, the declined lymphocytes counting was found in the most patients and considered to be a predictor in COVID-19 infection [9] [10] [11] . Laboratory studies also suggested that COVID-19 might mainly act on lymphocytes, especially T lymphocytes, ant the substantial decrease in lymphocytes counting indicated COVID-19 might inhibits cellular immune function [1] .

In terms of the findings in a severe patient we constantly monitored, the concentration of serum total cholesterol, HDL-cholesterol and LDL-cholesterol, as well as lymphocytes counting in the process of infection were able to effectively reflect the process of the disease, however, HDL-cholesterol concentration was especially significant (Fig. 2) . Notably, the changes of serum HDL-cholesterol were consistent with that of chest CT imaging examination and virus nucleic acid tests 11 (Figs. 3 A, B) , which are indicators associated with disease prognosis.

All of the above results suggested that HDL-cholesterol concentration might be closely associated with the progression and severity of COVID-19 infection. In our further analysis, ROC curve (AUC=0.732, Fig. 4 ) and adjusted OR value (0.023, Table 3 ) indicated that the value of HDL-cholesterol as an assessment of the severity of COVID-19 infection was appropriate.

Currently, COVID-19 infection-associated dyslipidemia had been reported in several clinical studies [6, 7, 12] , however, underlying mechanism of cholesterol metabolism in COVID-19 infection is still unknow. Hitherto, the most widely investigation of virus infection with dyslipidemia is HIV-associated dyslipidemia [13, 14] . In HIV-1 infection, low serum/plasma HDL-cholesterol was confirmed to be associated with the impairment of ATP-binding cassette transporter A1-dependent cholesterol efflux from macrophages, and the activation of endothelial lipase and phospholipase A2 by inflammation [15, 16] .

Although it is unclear whether declined serum HDL-cholesterol in COVID-19 infection shares the same mechanism as HIV-1 infection, HDL particles and cholesterol were indicated to be closely related to virus infection. The studies in vitro showed that cholesterol on lipid rafts was proved to be required for the early stage of SARS-CoV replication and during the binding stage of SARS-CoV entering host cells [17, 18] . Furthermore, HDL generally is an anti-inflammatory lipoprotein [19] [20] [21] .

However, inflammation was reported to leads to structural alterations of HDL particles and caused the accumulation of the acute phase protein serum amyloid A 12 (SAA) within the protein moiety of HDL [22] . SAA-enriched HDL particles lose the anti-inflammatory properties and even promoted the pro-inflammatory activation of macrophages and translocation of TLR4 into lipid rafts [23] . In view of these findings, we speculated that HDL lost its anti-inflammatory properties, as well as Our study has several limitations. As a retrospective study, our number of samples is small, as well as from single medical center, which might induce the deviation of the results. Additionally, the widely used antiviral treatment, such as Lopinavir, had been confirmed to lead to dyslipidemia. In contrast, interferon has little effect on lipid metabolism. Unfortunately, most of the patients were treated with Lopinavir, we only collected one case with interferon-a treatment and monitored the case constantly. If there are more, our conclusion will be more convincing.

Taken together, the patients with COVID-19 infection showed that serum HDLcholesterol concentration significantly declined in the early stage of the disease, especially in those severe infected patients. Based on our current analysis, decreased serum HDL-cholesterol is associated with the severity of COVID-19 infection. 

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Membrane Cholesterol Modulates Oligomeric Status and Peptide-Membrane Interaction of Severe Acute Respiratory Syndrome Coronavirus Fusion Peptide

National Health Commission of the People's Republic of China

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Low-density lipoprotein is a potential 14 predictor of poor prognosis in patients with coronavirus disease 2019

Hypolipidemia is associated with the severity of COVID-19

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Laboratory Parameters in Detection of COVID-19 Patients with Positive RT-PCR; a Diagnostic Accuracy Study

Platelet-to-lymphocyte ratio is associated with prognosis in patients with coronavirus disease-19

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Impact of HIV infection and HAART on serum lipids in men

Hypocholesterolemia is associated with immune dysfunction in early human immunodeficiency virus-1 infection

Human immunodeficiency virus impairs reverse cholesterol transport from macrophages

Molecular regulation of HDL metabolism and function: implications for novel therapies

Lipid rafts play an important role in the early stage of severe acute respiratory syndrome-coronavirus life cycle

Lipid rafts are involved in SARS-CoV entry into Vero E6 cells

Neutrophil activation is attenuated by high-density lipoprotein and apolipoprotein A-I in in vitro

in vivo models of inflammation

High-Density Lipoproteins Decrease Proinflammatory Activity and Modulate the Innate Immune Response

High-density lipoprotein reduces inflammation from cholesterol crystals by inhibiting inflammasome activation

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Serum amyloid A impairs the antiinflammatory properties of HDL

Title: Declined serum high density lipoprotein cholesterol is associated with the severity of COVID-19 infection Concise title: Declined serum HDL-cholesterol in COVID-19

Guiqing He, PhD; Department of Infectious Diseases

Wei Ye contributes to literature search, data analysis and writing Funding: Natural Science Foundation of Zhejiang Province (LQ18H020005) and Health Commission of Zhejiang Province

Commission of Zhejiang Province.