key: cord-1006101-z2kwnju0 authors: Alcántara-Alonso, Estefanía; Molinar-Ramos, Fernando; González-López, Jesús A.; Alcántara-Alonso, Viridiana; Muñoz-Pérez, Marco A.; Lozano-Nuevo, José Juan; Benítez-Maldonado, Daniel Rabindranath; Mendoza-Portillo, Elizabeth title: High triglyceride to HDL-cholesterol ratio as a biochemical marker of severe outcomes in COVID-19 patients date: 2021-05-07 journal: Clin Nutr ESPEN DOI: 10.1016/j.clnesp.2021.04.020 sha: ab9ea28c9cc191c177b2e03fd3dfa5722eb9f03e doc_id: 1006101 cord_uid: z2kwnju0 Background & aims Coronavirus disease 2019 (COVID-19) patients with severe complications have shown comorbidities with cardiovascular-disease, hypertension and type 2 diabetes mellitus; clinical disorders that share the common metabolic alterations of insulin resistance and dyslipidaemia. A high triglyceride to high density lipoprotein cholesterol (Tg/HDL c) ratio has been associated with reduced insulin sensitivity, metabolic syndrome and adverse cardiovascular events. Our aim in this study was to determine the association between different components of the lipid profile and particularly the Tg/HDL c ratio with severe complications like the requirement of invasive mechanical ventilation in COVID-19 patients. Methods We collected demographic, clinical and biochemical data to conduct a cohort study in 43 adult patients with confirmed COVID-19 diagnosis by quantitative polymerase chain reaction (qPCR) at baseline and in the subsequent 15 days. Patients were subjected to a very similar treatment scheme with the JAK1/2 inhibitor ruxolitinib. Descriptive statistics, variable association and logistic regression were applied to identify predictors of disease severity among elements and calculations from the lipid profile. Results Patients were aged 57±14 years; 55.8% were male from which 75% required hospitalization and 44.2% were female who 58% were hospitalized. The most common comorbidities were type 2 diabetes mellitus (58%) and hypertension (40%). Hospitalized and critical care patients showed lower HDL c blood levels and increased Tg/HDL c ratio than those with outpatient management and mild/asymptomatic COVID-19. Tg/HDL c ratio correlated with variables of disease severity such as lactate dehydrogenase (LDH) levels (r=0.356; p<0.05); the National Early Warning Score 2 (NEWS 2)(r=0.495; p<0.01); quick sequential organ failure assessment (qSOFA)(r=0.538; p<0.001); increased need of oxygen support (r=0.447; p<0.01) and requirement of mechanical ventilation (r=0.378; p<0.05). Tg/HDL c ratio have a negative correlation with partial oxygen saturation/fraction of inspired oxygen (SaO2/FiO2) ratio (r=-0.332;p<0.05). Linear regression analysis showed that Tg/HDL c ratio can predict increases in inflammatory factors like LDH (p<0.01); ferritin (p<0.01) and D-dimer (p<0.001). Logistic regression model indicated that ≥ 7.45 Tg/HDL c ratio predicts requirement of invasive mechanical ventilation (OR 11.815, CI 1.832-76.186, p<0.01). Conclusions The Tg/HDLc ratio can be used as an early biochemical marker of COVID-19 severe prognosis with requirement of invasive mechanical ventilation. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), also known as coronavirus disease 2019 is caused by a new positive-sense, single-stranded RNA virus which belongs to the β-coronaviruses lineage [1] . Around 80% of the COVID-19 infected patients are asymptomatic or develop very mild symptoms; however, in the remaining 20% a rapid disease progression leads to severe complications as hypoxemia (dyspnoea, central cyanosis and oxygen saturation lower than 92%), with the risk to develop respiratory distress syndrome; shock and multiple organ failure, increasing the mortality rate to more than 50% [2] . Severe COVID-19 has been linked to a proinflammatory cytokine storm defined as a massive release of tumour necrosis factor alpha (TNFα); interleukins (IL) IL-1β, IL-2, IL-6, IL-8; granulocyte colony-stimulating factor (G-CSF); along with reactive oxygen species and chemokines such as C-C motif chemokine ligands (CCL2, CCL3, CCL5) and interferon gamma-induced protein 10 (IP-10) [2, 3] . Little is known about the immunological response against SARS-CoV2; nevertheless, clinical trials with patients infected with other coronaviruses, SARS-CoV and MERS-CoV, shown that increases in the serum concentration of proinflammatory cytokines is linked with lung inflammation and extensive lung injury [4] . The cytokine storm in other coronavirus infections is the result of an increase in neutrophil number; monocyte and macrophage hyperactivation, and lymphocyte Th1/ Th17 activation in the adaptive immune system, intensifying the inflammatory response [3] . Trained immunity is a memory-like feature of cells from the innate immune system like monocytes which develop epigenetic changes when Toll-like receptors (TLR) are activated by diverse antigens, promoting increased release of proinflammatory cytokines in a second exposure to an antigen [5] . The enhanced response depends on the ligand concentration and the type of receptor activated during the first antigen exposure [5] . Remarkably, several endogenous ligands like saturated fatty acids, oxidized low-density lipoprotein and advanced glycation end products (AGEs) act as damage-associated molecular patterns (DAMPs) and are recognized by Toll-like receptors (TLR2 and TLR4) [6] , activating inflammatory responses. Patients with metabolic syndrome and insulin resistance commonly have higher concentration of these endogenous ligands; therefore, trained immunity could be involved in the increased synthesis of proinflammatory cytokines by the immune system of patients when infected with SARS-CoV-2 [7] . Compared with mild or asymptomatic COVID-19 patients, individuals with severe complications have higher prevalence of comorbidities such as hypertension, cardiovascular disease and type 2 diabetes mellitus [8] . These comorbidities share the common metabolic alterations of insulin resistance and dyslipidaemia; the later has been linked to severe COVID-19 by Choi et al. [9] and Hariyanto et al. [10] . The triglyceride to High Density Lipoprotein-cholesterol (Tg/HDL c) ratio has been associated with reduced insulin sensitivity [11] and adverse cardiovascular events [12] and has even been considered as a better marker of cardiovascular risk than serum concentrations of high-or low-density lipoproteins cholesterol (HDL c or LDL c) alone [12] . Given the lack of studies about a possible association between COVID-19 severity with different components of the lipid profile and particularly with the Tg/HDL c ratio; which represents an easy and affordable estimation of insulin resistance and cardiovascular risk; we here associate this ratio at the time of COVID-19 diagnosis with biochemical values of severity and the development of complications, identifying it as an early marker of negative prognosis. J o u r n a l P r e -p r o o f The research ethics review board at Secretaría de salud de la Ciudad de México (SEDESA) approved the protocol as it represents minimum risk and is in accordance with the WMA Declaration of Helsinki. All participants or their relatives provided written informed consent. This is an observational cohort study using clinical data of 43 adult patients, 24 (55.8%) male and 19 (44.1%) female admitted from May to October 2020 in our institution with COVID-19 infection, confirmed by quantitative reverse transcriptase-polymerase chain reaction (qRT-PCR) from nasopharyngeal swab specimens in addition to characteristic symptomatology and computerized thoracic tomography imaging. Patients who had previous dyslipidaemia treatment, uncontrolled type 2 diabetes mellitus or chronic kidney or liver disease were not included. All patients received a standard clinical laboratory sampling at the baseline (COVID-19 diagnosis). Biochemical parameters were performed on DxC 700 AU chemistry analyser. All laboratory assays had completed the standardization and certification program. Epidemiologic and demographic features as well as the biochemical lipid profile including triglycerides (Tg), total HDL c and LDL c levels were archived. Tg/HDL c ratio was calculated. Other analyses include: hemogram, renal function tests (C cystatin, blood urea nitrogen, creatinine) and severity biochemical parameters (D-dimer, C reactive protein The criteria for severe COVID-19 were a respiratory rate > 30/min; O2 saturation < 93% and/or SaO2/FiO2 <160 (severe ARDS Acute Respiratory Distress Syndrome by Kigali criteria) and for critical care COVID-19 were requirement of invasive mechanical ventilation, shock and/or multiple organ failure. In this study both, outpatient management and hospitalized patients had antipyretic drugs and 5 mg/12 h of the JAK1/2 inhibitor ruxolitinib in patients with no-requirement of mechanical ventilation and 10 mg/1 2h in patients with mechanical ventilation. All hospitalized patients also had treatment with 6 mg/24 h of dexamethasone for 10 days and low-molecular weight heparin. Patients with critical care COVID-19 were treated at the intensive care unit of our institution. Descriptive tabulation was done using data about age, sex, weight, comorbidities, biochemistry, acute kidney injury, requirement of invasive mechanical ventilation, vasopressor support, days of hospitalization and mortality. The Shapiro-Wilks test was employed to determine normality of data distribution. Statistical analysis of the categorical data was performed using the Chi-square and Fisher exact test. Student´s t-test was used to compare continuous values between two groups in which case data were normally distributed and non-parametric Mann-Witney U test used when data were not normally distributed. Kruskal-Wallis test was used to compare continuous values between three groups in which case data were not normally distributed and followed by a Games-Howell Finally, a multivariate logistic regression analysis adjusted to age, sex and cut-off points calculated for HDL c and the Tg/HDL c ratio was conducted for the requirement of invasive mechanical ventilation with successive steps backward (conditional) method. Data were analysed using IBM SPSS version 20. Statistical differences were considered significant when p-values were < 0.05. Outpatient management were done in 14 individuals while 29 developed severe COVID-19 and were hospitalized. The age was not different between outpatient and hospitalized treatment. Demographic features are shown in Table 1 . The most common comorbidities were type 2 diabetes mellitus and hypertension with higher prevalence (2.6 and 1.8 times higher respectively) in hospitalized than outpatient management, Table 1 . Other comorbidities were chronic obstructive pulmonary disease (COPD) in 4 patients, ischemic cardiomyopathy in 2 patients and vitiligo in 1 patient. There were statistically significant changes (p<0.001) with a 3.6 times higher NEWS 2 and 11-fold increased qSOFA score as well as decreased SaO2/FiO2 ratio in hospitalized versus outpatient management Table 1 . Regarding the lipid profile, they showed 25 % lower HDL c blood levels (p<0.01) and increased Tg/HDL c (2.7-fold) ratio than those of outpatient management (p<0.01) Table 2 . These differences were also observed between the critical care COVID-19 patients and the ones with mild symptoms, Games-Howell post-hoc test indicate significant lower HDL c (p<0.05) and higher Tg/HDL c ratio (p<0.05) levels Table 3 . HDL c blood concentration ≤35 mg/dL and Tg/HDL c ratio ≥ 7.45 also predicted a NEWS 2 ≥ 2 Figure 3 . Binomial multivariate logistic regression revealed that ≤35 mg/dL HDL c blood concentration and ≥ 7.45 Tg/HDL c ratio are predictors adjusted by age and gender for the requirement of invasive mechanical ventilation Table 5 . Key factors linked to the development of cardiovascular disease, hypertension and type 2 diabetes mellitus are obesity, dyslipidemia and insulin resistance [13] . Mexico has a high prevalence of metabolic syndrome and related chronic diseases. According to the most recent national health and nutrition survey (Encuesta Nacional de This high mortality rate in COVID-19 patients may be related with the elevated risk to develop severe complications in individuals with cardiovascular disease, hypertension and type 2 diabetes mellitus [8] . As dyslipidaemia is a common feature in these metabolic disorders and has been linked with severe COVID-19 [9, 10] ; our results confirm that J o u r n a l P r e -p r o o f dyslipidaemia and particularly a high Tg/HDL c ratio at the time of COVID-19 diagnosis can be used as a prognosis factor for disease severity and requirement for invasive mechanical ventilation. Although we found no differences in gender, age or comorbidities between hospitalized versus outpatient management, a higher percentage of men 75%, required hospitalization compared with 57.8% of women; a point already observed for COVID-19 complications and viremia [8, 18, 19] . Additionally, 72% of patients with type 2 diabetes mellitus and 64.7% with hypertension were hospitalized. These are commonly reported comorbidities in hospitalized COVID-19 patients [8, 18, 19] . Our analysis revealed that a low plasmatic level of HDL c and elevated Tg/HDL c ratio at the time of COVID-19 diagnosis is linked with requirement of hospitalization and illness severity as critical care patients showed the lowest HDL c concentration and highest Tg/HDL c compared with severe and mild/asymptomatic COVID-19 patients. Elevated Tg and low HDL c were constantly associated with clinical and biochemical data of COVID-19 severity like increased LDH levels which is an inflammatory marker previously proposed as predictor of poor prognosis in COVID-19 patients [20, 21] and with NEWS 2 an early warning score published by the Royal College of Physicians [22] with a good performance in the prediction of severity and mortality in COVID-19 patients [22] [23] [24] . A low HDL c concentration was additionally linked with high ferritin levels, a protein associated with inflammatory processes and previously reported increased in severe COVID-19 patients [25] , related with SARS-CoV-2 viremia [18] and proposed as predictor of mortality for the disease [26, 27] . In addition, low HDL c levels were associated with high qSOFA, another early warning score associated with COVID-19 mortality [27] . Remarkably, we found negative correlations between plasmatic HDL c and length of hospitalization along with requirement of invasive mechanical ventilation and a positive correlation with SaO2/FiO2 index, all variables related to the severity of COVID-19. Our results are in line with those reported previously [28] [29] [30] of a higher prevalence of severe COVID-19 cases in patients with low HDL c levels. There is also observed an association between lower concentrations of apolipoprotein ApoA1, one of its major structural components, which is inversely correlated with inflammatory states, disease severity and mortality [30, 31] . HDL c has immunomodulatory effects via its binding to pathogen-associated molecules like bacterial-lipopeptides (lipopolysaccharide, lipoteichoic acid) [32] and diacylated peptides like Pam2CSK4, FSL-1 which neutralize the infectious activity by blocking TLR2 and TLR4 responses [33] as well as by inhibiting the production of inflammatory cytokines by macrophages [34] . Besides, elevated serum HDL c can also promote proliferation of IgA in early stages of bacterial infection [35] , but it is not known if a similar mechanism could be prevented COVID-19 viremia and derived complications. Nevertheless, as HDL c particles transport paraoxonase 1 which has antiviral properties; this could induce virus inactivation [36] and ApoA1 has shown protective effects in several lung disease conditions, including viral pneumonia [37] although the molecular mechanism involved is not yet elucidated. Given the observed associations of clinical and biochemical markers of severity with high Tg and low HDL c, our analysis of Tg/HDL c ratio correlations reveal positive associations with LDH, NEWS 2, qSOFA, length of hospitalization, requirement of invasive mechanical ventilation and a positive correlation with SaO2/FiO2 index. To our knowledge this is the first study assessing the correlation between Tg /HDL c ratio and COVID-19 complications. Tg/HDL c ratio has been considered as a better marker of cardiovascular risk than serum concentrations of HDL c and LDL c alone [12] and given its good correlation with the hyperinsulinemic-euglycemic clamp, an accurate estimation of insulin sensitivity; Tg/HDL c ratio can also reflect glucose-metabolic alterations [38] . Hyperinsulinemia of patients with insulin resistance and diabetes could also contribute to increased SARS-CoV-2 viremia [18] as insulin increases membrane expression of angiotensin-converting enzyme 2 (ACE 2) in pneumocyte [39] which function as receptor of the SARS-CoV-2 spike protein causing the cell infection. In our study, higher Tg/HDL c ratio were observed in hospitalized versus outpatient management and in critical care patients versus mild/asymptomatic individuals. Additionally, high Tg/HDL c ratio were also correlated with increased need for oxygen support. Greater risk to develop complications and requirement of oxygen assistance are reported in COVID-19 patients with diabetes [18, 19] . Hyperinsulinaemia and hyperglycaemia increase inflammation and risk of thrombosis by increasing coagulation [40] . Hyperinsulinemia increases plasminogen activator type 1 levels, promoting thrombi by inhibition of fibrinolysis while hyperglycaemia increase blood coagulation and production of proinflammatory cytokines TNF-alpha and IL-6 [41] . Pulmonary thrombi may contribute to oxygen desaturation and respiratory distress in COVID-19 cases [40] and this could be promoted by insulin resistance which raise glucose and insulin circulating levels. However, more studies are needed to associate hyperinsulinemia with inflammatory and thrombotic processes in COVID-19 and its direct link with Tg/HDL c ratio in severe patients could indicate hypoxemia and deficient pulmonary function in COVID-19 severe and critical patients. Our results emphasize the use of parameters of the lipid profile such as HDL c level as a marker of risk for severe COVID-19 outcomes. Moreover, our findings disclose that the Tg/HDL c ratio is a novel biochemical marker of severe prognosis and requirement of invasive mechanical ventilation in COVID-19 patients. Secretaría de salud de la Ciudad de México (SEDESA). SARS-Cov-2 infection: Response of human immune system and possible implications for the rapid test and J o u r n a l P r e -p r o o f treatment Epidemiology of COVID-19 (Special Issue: COVID-19 pandemic) The pathogenesis and treatment of the 'Cytokine Storm'' in COVID-19 Immune response in COVID-19: What do we currently know? Trained immunity or tolerance: Opposing functional programs induced in human monocytes after engagement of various pattern recognition receptors Toll-like receptor status in obesity and metabolic syndrome: A translational perspective Increased toll-like receptor activity in patients with metabolic syndrome Risk factors of critical & mortal COVID-19 cases: A systematic literature review and meta-analysis The potential role of dyslipidemia in covid-19 severity: An umbrella review of systematic reviews Dyslipidemia is associated with severe coronavirus disease 2019 (COVID-19) infection. Diabetes and Metabolic Syndrome Triglyceride/high-density lipoprotein cholesterol (TG/HDL-C) index as a reference criterion of risk for metabolic syndrome (MetS) and low insulin sensitivity in apparently healthy subjects Triglyceride to High-Density Lipoprotein Cholesterol Ratio and Cardiovascular Events in Diabetics With Coronary Artery Disease Association between insulin resistance and the development of cardiovascular disease Prevalencia de diabetes y descontrol glucemico en Mexico: Resultados de la Ensanut Dyslipidemia prevalence, awareness, treatment and control in Mexico: results of the Ensanut 2012. Salud Pública de Méxic o 2020 SARS-CoV-2 viremia is associated with inflammatory, but not cardiovascular biomarkers, in patients hospitalized for COVID-19 Thromboinflammatory Biomarkers in COVID-19: Systematic Review and Meta-analysis of 17,052 patients Factors associated with death outcome in patients with severe coronavirus disease-19 (Covid-19): A case-control study Outcomes in Patients With COVID-19 Disease and High Oxygen Requirements National Early Warning Score 2 (NEWS2) to identify inpatient COVID-19 deterioration: a retrospective analysis National Early Warning Score 2 (NEWS2) on admission predicts severe disease and in-hospital mortality from Covid-19 -A prospective cohort study The performance of the National Early Warning Score and National Early Warning Score 2 in hospitalised patients infected by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Ferritin levels and COVID-19 Evaluation of serum ferritin for prediction of severity and mortality in COVID-19-A cross sectional study Identifying critically ill patients at risk of death from coronavirus disease Low high-density lipoprotein level is correlated with the severity of COVID-19 patients: An observational study Cholesterol Metabolism-Impacts on SARS-CoV-2 Infection Prognosis Metabolic disturbances and inflammatory dysfunction predict severity of coronavirus disease 2019 (COVID-19): A retrospective study Lipid Profile Features and Their Associations With Disease Severity and Mortality in Patients With COVID-19 COVID-19-Associated dyslipidemia: Implications for mechanism of impaired resolution and novel therapeutic approaches Lipoproteins attenuate TLR2 and TLR4 activation by bacteria and bacterial ligands with differences in affinity and kinetics High-density lipoprotein mediates anti-inflammatory reprogramming of macrophages via the transcriptional regulator ATF3 Nutritional status positively impacts humoral immunity against its Mycobacterium tuberculosis, disease progression, and vaccine development Cholesterol, lipoproteins, and COVID-19: Basic concepts and clinical applications High-density lipoproteins and apolipoprotein A-I: Potential new players in the prevention and treatment of lung disease Insulin sensitivity indices obtained from oral glucose tolerance testing: Comparison with the euglycemic insulin clamp Coronavirus and Obesity: Could Insulin Resistance Mediate the Severity of Covid-19 Infection? Frontiers in Public Health 2020 Relationships between hyperinsulinaemia, magnesium, vitamin D, thrombosis and COVID-19: rationale for clinical management Hyperglycemia stimulates coagulation, whereas hyperinsulinemia impairs fibrinolysis in healthy humans Low Serum Cholesterol Level Among Patients with COVID-19 Infection in Wenzhou The authors declare no competing interests.