Association of liver abnormalities with in-hospital mortality in patients with COVID-19

Association of liver function and prognosis in patients with severe fever with thrombocytopenia syndrome

OBJECTIVES

Severe fever with thrombocytopenia syndrome (SFTS) is an epidemic emerging infectious disease with high mortality rate. We investigated the association between liver injury and clinical outcomes in patients with SFTS.

METHODS

A total of 291 hospitalized SFTS patients were retrospectively included. Cox proportional hazards model was adopted to identify risk factors of fatal outcome and Kaplan-Meier curves were used to estimate cumulative risks.

RESULTS

60.1% of patients had liver injury at admission, and the median alanine transaminase, aspartate aminotransferase (AST), alkaline phosphatase (ALP), and total bilirubin (TBil) levels were 76.4 U/L, 152.3 U/L, 69.8 U/L and 9.9 μmol/L, respectively. Compared to survivors, non-survivors had higher levels of AST (253.0 U/L vs. 131.1 U/L, P < 0.001) and ALP (86.2 U/L vs. 67.9 U/L, P = 0.006), higher proportion of elevated ALP (20.0% vs. 4.4%, P < 0.001) and liver injury (78.5% vs. 54.9%, P = 0.001) at admission. The presence of liver injury (HR 2.049, P = 0.033) at admission was an independent risk factor of fatal outcome.

CONCLUSIONS

Liver injury was a common complication and was strongly associated with poor prognosis in SFTS patients. Liver function indicators should be closely monitored for SFTS patients.

Predictors of in-hospital mortality in elderly unvaccinated patients during SARS-CoV-2 Alpha variants epidemic

Background

COVID-19, caused by SARS-CoV-2, has caused a global pandemic. This study aimed to identify predictors of in-hospital mortality in unvaccinated elderly patients with COVID-19 by comparing various predictive factors between the survivors and non-survivors.

Methods

We retrospectively selected 132 unvaccinated patients aged over 65 years with COVID-19 at a hospital in Kanagawa, Japan, during SARS-CoV-2 Alpha variants epidemic. We compared the clinical characteristics, laboratory and radiological findings, treatment, and complications of the survivors and non-survivors. In logistic regression analysis, variables that were significant in the univariate analysis were subjected to multivariate analysis using the variable increase method.

Results

There were 119 and 13 patients in the survivor and non-survivor groups, respectively. Multivariate regression revealed increasing odds with the presence of ARDS and DIC (odd ratio (OR) = 16.35, 34.36; P=0.002, 0.001, respectively) and prolonged hospital stay (OR = 1.17; P=0.004).

Conclusions

We found the complications of ARDS and DIC and hospital length of stay to be independent predictors of in-hospital mortality in elderly unvaccinated patients with COVID-19. Establishing treatments and prevention methods for ARDS and DIC could result in lower mortality rates.

A multi-center study to predict the risk of intraoperative hypothermia in gynecological surgery patients using preoperative variables

OBJECTIVES

Hypothermia is highly common in patients undergoing gynecological surgeries under general anesthesia, so the length of hospitalization and even the risk of mortality are substantially increased. Our aim was to develop a simple and practical model to preoperatively identify gynecological surgery patients at risk of intraoperative hypothermia.

METHODS

In this retrospective study, we collected data from 802 patients who underwent gynecological surgery at three medical centers from June 2022 to August 2023. We further allocated the patients to a training group, an internal validation group, or an external validation group. The preliminary predictive factors for intraoperative hypothermia in gynecological patients were determined using the least absolute shrinkage and selection operator (LASSO) method. The final predictive factors were subsequently identified through multivariate logistic regression analysis, and a nomogram for predicting the occurrence of hypothermia was established.

RESULTS

A total of 802 patients were included, with 314 patients in the training cohort (mean age 48.5 ± 12.6 years), 130 patients in the internal validation cohort (mean age 49.9 ± 12.5 years), and 358 patients in the external validation cohort (mean age 47.6 ± 14.0 years). LASSO regression and multivariate logistic regression analyses indicated that body mass index, minimally invasive surgery, baseline heart rate, baseline body temperature, history of previous surgery, and aspartate aminotransferase level were associated with intraoperative hypothermia in gynecological surgery patients. This nomogram was constructed based on these six variables, with a C-index of 0.712 for the training cohort.

CONCLUSIONS

We established a practical predictive model that can be used to preoperatively predict the occurrence of hypothermia in gynecological surgery patients.

CLINICAL TRIAL REGISTRATION

chictr.org.cn, identifier ChiCTR2300071859.

COVID-19, Possible Hepatic Pathways and Alcohol Abuse-What Do We Know up to 2023?

The pandemic period due to coronavirus disease 2019 (COVID-19) revolutionized all possible areas of global health. Significant consequences were also related to diverse extrapulmonary manifestations of this pathology. The liver was found to be a relatively common organ, beyond the respiratory tract, affected by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Multiple studies revealed the essential role of chronic liver disease (CLD) in the general outcome of coronavirus infection. Present concerns in this field are related to the direct hepatic consequences caused by COVID-19 and pre-existing liver disorders as risk factors for the severe course of the infection. Which mechanism has a key role in this phenomenon-previously existing hepatic disorder or acute liver failure due to SARS-CoV-2-is still not fully clarified. Alcoholic liver disease (ALD) constitutes another not fully elucidated context of coronavirus infection. Should the toxic effects of ethanol or already developed liver cirrhosis and its consequences be perceived as a causative or triggering factor of hepatic impairment in COVID-19 patients? In the face of these discrepancies, we decided to summarize the role of the liver in the whole picture of coronavirus infection, paying special attention to ALD and focusing on the pathological pathways related to COVID-19, ethanol toxicity and liver cirrhosis.

Liver dysfunction and clinical outcomes of unvaccinated COVID-19 patients with and without chronic hepatitis B

BACKGROUND

Liver dysfunction is common during coronavirus disease 2019 (COVID-19), while its clinical impact and association with chronic hepatitis B (CHB) remain uncertain. We aimed to investigate liver dysfunction in COVID-19 patients and its impacts on those with/without CHB.

METHODS

We conducted a retrospective cohort study of COVID-19 patients at National Taiwan University Hospital, stratified according to hepatitis B surface antigen (HBsAg) serostatus, with demographics, laboratory data, and hospitalization course reviewed, and clinical outcomes compared through multivariable analyses.

RESULTS

We enrolled 109 COVID-19 patients unvaccinated against SARS-CoV-2 by August 2021. The HBsAg-positive group (n = 34) had significantly higher alanine aminotransferase (ALT) (26 vs. 16 U/L, P = 0.034), platelet (224 vs. 183 k/μL, P = 0.010) and longer hospitalizations (17 vs. 13 days, P = 0.012) compared with HBsAg-negative group (n = 75), while percentages of hepatitis (2-fold ALT elevation), oxygen supplementation, ventilators usage, COVID-specific treatment, intensive care unit (ICU) admission and mortality were comparable. Older age (odds ratio [OR]: 1.04, 95 % confidence interval [CI]: 1.00-1.08, P = 0.032) and higher aspartate aminotransferase (AST) (OR: 1.08, 95 % CI: 1.004-1.16, P = 0.038) were associated with oxygen supplementation according to multivariable analyses. Higher AST predicted ICU admission (OR: 1.11, 95 % CI: 1.03-1.19, P = 0.008). Oxygen usage (OR: 5.64, 95 % CI: 1.67-19.09, P = 0.005) and shock (OR: 5.12, 95 % CI: 1.14-22.91, P = 0.033) were associated with liver dysfunction.

CONCLUSIONS

CHB patients had higher ALT levels and longer hospitalizations during COVID-19. Higher AST levels predict severe COVID-19 and ICU admission.

Altered Liver Biochemistry and Mortality in Patients Hospitalized With COVID-19

COVID-19 is an illness caused by the SARS-CoV-2 virus, a type of coronavirus initially identified in China in late 2019, emerging as the leading cause of death attributed to a single infectious agent worldwide. The COVID-19 pandemic poses a substantial challenge to global public health in the first quarter of this century. The rapid evolution of the pandemic and its intricate response have hindered the formulation of definitive conclusions, and it may take years to comprehend its long-term effects. Assessing the extent of organ damage beyond the lungs could guide physicians in the disease's severity or progression. Based on these characteristics, an earlier and more targeted approach can be initiated at the appropriate moment. The association between hepatic profile and mortality in COVID-19 patients is a subject of scientific interest, as SARS-CoV-2 infection can lead to hepatitis. In severe cases, it may induce sepsis-related liver injury, potentially culminating in hepatic failure.

METHODOLOGY

The study's objective is to determine the prevalence of mortality in adult patients with elevated hepatic profile hospitalized due to SARS-CoV-2 infection. This cross-sectional, monocentric study was conducted at a healthcare institution in Bogotá, Colombia.

RESULTS

This study includes 91 patients with confirmed diagnoses of COVID-19, revealing a prevalence of hepatic profile alterations in 61.5% (n=56) of hospitalized patients. The mortality rate observed is 17.6% (n= 16), with an odds ratio (OR) of 12.4 (95% CI = 1.56-99.0) in patients with hepatic profile alterations.

CONCLUSIONS

This research underscores the importance of early detection of hepatic profile alterations in hospitalized patients with COVID-19. Not only are these alterations prevalent, but they are also potentially associated with an increased risk of mortality. These findings emphasize the necessity for further research to enhance strategies and prognostication for patients with COVID-19 in the future.

Liver injury due to COVID-19 in critically ill adult patients. A retrospective study

INTRODUCTION AND AIM

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged, causing the current pandemic of acute respiratory disease known as COVID-19. Liver injury due to COVID-19 is defined as any liver injury occurring during the course of the disease and treatment of patients with COVID-19, with or without liver disease. The incidence of elevated liver transaminases, alanine aminotransferase (ALT) and aspartate aminotransferase (AST), ranges from 2.5 to 76.3%. The aim of the present study was to describe the hepatic biochemical abnormalities, after a SARS-CoV-2-positive polymerase chain reaction (PCR) test, and the mortality rate in critically ill patients.

MATERIALS AND METHODS

A retrospective study was conducted that included 70 patients seen at a private hospital in Mexico City, within the time frame of February-December 2021. Median patient age was 44.5 years (range: 37-57.2) and 43 (61.4%) of the patients were men. Liver function tests were performed on the patients at hospital admission.

RESULTS

Gamma glutamyl transferase (GGT) levels were elevated (p = 0.032), as were those of AST (p = 0.011) and ALT (p = 0.021). The patients were stratified into age groups: 18-35, 36-50, and > 50 years of age. The 18 to 35-year-olds had the highest liver enzyme levels and transaminase levels were higher, the younger the patient. Due to the low mortality rate (one patient whose death did not coincide with a hepatic cause), the multivariate analysis showed an R2 association of 0.689, explained by AST, GGT, and C-reactive protein levels.

CONCLUSIONS

Despite the increase in transaminases in our study population during the course of COVID-19, there was no increase in mortality. Nevertheless, hospitalized patient progression should be continuously followed.

Inactivated vaccines reduce the risk of liver function abnormality in NAFLD patients with COVID-19: a multi-center retrospective study

BACKGROUND

Abnormal liver function was frequently observed in nonalcoholic fatty liver disease (NAFLD) patients infected with SARS-CoV-2. Our aim was to explore the effect of SARS-CoV-2 inactivated vaccines on liver function abnormality among NAFLD patients with COVID-19.

METHODS

The multi-center retrospective cohort included 517 NAFLD patients with COVID-19 from 1 April to 30 June 2022. Participants who received 2 doses of the vaccine (n = 274) were propensity score matched (PSM) with 243 unvaccinated controls. The primary outcome was liver function abnormality and the secondary outcome was viral shedding duration. Logistic and Cox regression models were used to calculate the odds ratio (OR) and hazard ratio (HR) for the outcomes. Sensitivity analysis was conducted to assess robustness.

FINDINGS

PSM identified 171 pairs of vaccinated and unvaccinated patients. Liver function abnormality was less frequent in the vaccinated group (adjusted OR, 0.556 [95% CI (confidence interval), 0.356-0.869], p = 0.010). Additionally, the vaccinated group demonstrated a lower incidence of abnormal bilirubin levels (total bilirubin: adjusted OR, 0.223 [95% CI, 0.072-0.690], p = 0.009; direct bilirubin: adjusted OR, 0.175 [95% CI, 0.080-0.384], p < 0.001) and shorter viral shedding duration (adjusted HR, 0.798 [95% CI, 0.641-0.994], p = 0.044) than the unvaccinated group. Further subgroup analysis revealed similar results, while the sensitivity analyses indicated consistent findings.

INTERPRETATION

SARS-CoV-2 vaccination in patients with NAFLD may reduce the risk of liver dysfunction during COVID-19. Furthermore, vaccination demonstrated beneficial effects on viral shedding in the NAFLD population.

FUNDING

23XD1422700, Tszb2023-01, Zdzk2020-10, Zdxk2020-01, 2308085J27 and JLY20180124.

The Role of Aspartate Aminotransferase-to-Lymphocyte Ratio Index (ALRI) in Predicting Mortality in SARS-CoV-2 Infection

COVID-19 has a mortality rate exceeding 5.4 million worldwide. The early identification of patients at a high risk of mortality is essential to save their lives. The AST-to-lymphocyte ratio index (ALRI) is a novel biomarker of survival in patients with hepatocellular carcinoma, an organ susceptible to SARS-CoV-2 infection. For this study, the prognostic value of ALRI as a marker of COVID-19 mortality was evaluated. For this purpose, ALRI was compared with the main biomarkers for COVID-19 mortality (neutrophil-to-lymphocyte ratio [NLR], systemic immune-inflammation index [SII], platelet-to-lymphocyte ratio [PLR], lactate dehydrogenase (LDH)/lymphocyte ratio [LDH/LR]). A retrospective cohort of 225 patients with SARS-CoV-2 infection and without chronic liver disease was evaluated. In the non-survival group, the ALRI, NLR, SII, and LDH/LR were significantly higher than in the survival group (pcorrected < 0.05). ALRI had an area under the curve (AUC) of 0.81, a sensitivity of 70.37%, and a specificity of 75%, with a best cut-off value >42.42. COVID-19 patients with high ALRI levels had a mean survival time of 7.8 days. Multivariate Cox regression revealed that ALRI > 42.42 (HR = 2.32, 95% CI: 1.35-3.97; pcorrected = 0.01) was a prognostic factor of COVID-19 mortality. These findings prove that ALRI is an independent predictor of COVID-19 mortality and that it may help identify high-risk subjects with SARS-CoV-2 infection upon admission.

Hospital Admission Factors Independently Affecting the Risk of Mortality of COVID-19 Patients

INTRODUCTION

COVID-19 is a disease characterized by high in-hospital mortality, which seems to be dependent on many predisposing factors.

OBJECTIVES

The aim of this study was to analyze the clinical symptoms, abnormalities in the results of laboratory tests, and coexisting chronic diseases that independently affected the risk of in-hospital mortality in patients with COVID-19.

PATIENTS AND METHODS

We analyzed the records of patients with COVID-19 who were hospitalized from 6 March 2020 to 30 November 2021.

RESULTS

Out of the entire group of 2138 patients who were analyzed, 12.82% died during hospitalization. In-hospital mortality was independently associated with older age (OR 1.53, 95% CI 1.20-1.97); lower arterial blood oxygen saturation (OR 0.95, 95% CI 0.92-0.99); the presence of a neoplasm (OR 4.45, 95% CI 2.01-9.62), a stomach ulcer (OR 3.35, 95% CI 0.94-11.31), and dementia (OR 3.40, 95% CI 1.36-8.26); a higher score on the SOFA scale (OR 1.73, 95% CI 1.52-1.99); higher lactate dehydrogenase (LDH) (OR 1.08, 95% CI 1.05-1.12); higher N-terminal pro-brain natriuretic peptide (NT pro BNP) (OR 1.06, 95% CI 1.01-1.11); and lower total bilirubin in blood concentration (OR 0.94, 95% CI 0.90-0.99).

CONCLUSIONS

We found that low oxygen saturation, old age, and the coexistence of cancer, gastric ulcers, and dementia syndrome were variables that independently increased mortality during hospitalization due to COVID-19. Moreover, we found that decreased platelet count and bilirubin concentration and increased levels of LDH and NT-proBNP were laboratory test results that independently indicated a higher risk of mortality. We also confirmed the usefulness of the SOFA scale in predicting treatment results. The ability to identify mortality risk factors on admission to hospital will facilitate both adjusting the intensity of treatment and the monitoring of patients infected with SARS-CoV-2.

Association between acute liver injury & severity and mortality of COVID-19 patients: A systematic review and meta-analysis

Background

Acute liver injury (ALI), a complication often seen in COVID-19 patients, can lead to severe liver damage, multi-organ failure, acute vascular events, and can potentially escalate to patient mortality. Given this, we initiated a meta-analysis to investigate the correlation between ALI and adverse outcomes in COVID-19 patients.

Methods

We conducted an exhaustive search of databases, including Medline, Embase, PubMed Central, ScienceDirect, Google Scholar, and the Cochrane Library, from the November 2019 until January 2022. The quality of the included studies was evaluated using the Newcastle Ottawa (NO) scale. Our meta-analysis was carried out using a random-effects model and results were presented as pooled odds ratios (ORs) with their corresponding 95% confidence intervals (CIs).

Results

Our analysis incorporated 20 studies involving a total of 13,850 participants, predominantly from China and the United States. According to the NO scale, the majority of these studies were categorized as low-quality. Patients with ALI faced approximately 7 times higher odds of severe COVID-19 symptoms (pooled OR = 7.09; 95%CI: 4.97 to 10.12) and over 5 times higher odds of mortality (pooled OR = 5.50; 95%CI: 3.37 to 8.99) when compared to those without ALI.

Conclusion

Our findings affirm that ALI is a potent predictor of adverse outcomes, including severity and mortality, among COVID-19 patients. Recognizing and promptly addressing ALI in COVID-19 patients could be pivotal in improving prognosis and tailoring individualized patient management strategies. This underscores the need for clinicians to be vigilant about liver complications in the COVID-19 patients and integrate appropriate interventions in the treatment paradigm.

Fib-4 score is able to predict intra-hospital mortality in 4 different SARS-COV2 waves

Increased values of the FIB-4 index appear to be associated with poor clinical outcomes in COVID-19 patients. This study aimed to develop and validate predictive mortality models, using data upon admission of hospitalized patients in four COVID-19 waves between March 2020 and January 2022. A single-center cohort study was performed on consecutive adult patients with Covid-19 admitted at the Fondazione Policlinico Gemelli IRCCS (Rome, Italy). Artificial intelligence and big data processing were used to retrieve data. Patients and clinical characteristics of patients with available FIB-4 data derived from the Gemelli Generator Real World Data (G2 RWD) were used to develop predictive mortality models during the four waves of the COVID-19 pandemic. A logistic regression model was applied to the training and test set (75%:25%). The model's performance was assessed by receiver operating characteristic (ROC) curves. A total of 4936 patients were included. Hypertension (38.4%), cancer (12.15%) and diabetes (16.3%) were the most common comorbidities. 23.9% of patients were admitted to ICU, and 12.6% had mechanical ventilation. During the study period, 762 patients (15.4%) died. We developed a multivariable logistic regression model on patient data from all waves, which showed that the FIB-4 score > 2.53 was associated with increased mortality risk (OR = 4.53, 95% CI 2.83-7.25; p ≤ 0.001). These data may be useful in the risk stratification at the admission of hospitalized patients with COVID-19.

The impact of HBV infection on clinical outcomes of COVID-19 patients: a systematic review and meta-analysis

The impact of hepatitis B virus (HBV) infection on clinical outcomes of coronavirus disease 2019 (COVID-19) remains unclear. The aim of this study is to explore this impact. For this systematic review and meta-analysis, we searched PubMed, Web of Science, Embase, Cochrane library, China National Knowledge Infrastructure (CKNI), China Science and Technology Journal Database (VIP), and Wan Fang database for articles between 1 January 2020 and 1 February 2023. We used the Newcastle-Ottawa Quality Assessment to evaluate the study's quality. A random-effects meta-analysis was performed utilising the rates of severe/critical illness and death in COVID-19 patients with and without HBV infection. Eighteen studies with a total of 40,502 participants met the inclusion criteria. The meta-analysis showed that compared to those without HBV infection, COVID-19 patients with HBV were at increased risk of mortality (OR = 1.65, I2 = 58%, and 95% CI 1.08-2.53) and severity (OR = 1.90, I2 = 44%, and 95% CI 1.62-2.24). The region and gender may influence the outcomes of COVID-19 patients with HBV infection, but it requires more global data to confirm. In conclusion, HBV infection is significantly linked to an increased risk of severity and mortality in COVID-19.

COVID-19 and severity of liver diseases: Possible crosstalk and clinical implications

COVID-19-infected individuals and those who recovered from the infection have been demonstrated to have elevated liver enzymes or abnormal liver biochemistries, particularly with preexisting liver diseases, liver metabolic disorders, viral hepatitis, and other hepatic comorbidities. However, possible crosstalk and intricate interplay between COVID-19 and liver disease severity are still elusive, and the available data are murky and confined. Similarly, the syndemic of other blood-borne infectious diseases, chemical-induced liver injuries, and chronic hepatic diseases continued to take lives while showing signs of worsening due to the COVID-19 crisis. Moreover, the pandemic is not over yet and is transitioning to becoming an epidemic in recent years; hence, monitoring liver function tests (LFTs) and assessing hepatic consequences of COVID-19 in patients with or without liver illnesses would be of paramount interest. This pragmatic review explores the correlations between COVID-19 and liver disease severity based on abnormal liver biochemistries and other possible mechanisms in individuals of all ages from the emergence of the COVID-19 pandemic to the post-pandemic period. The review also alludes to clinical perspectives of such interactions to curb overlapping hepatic diseases in people who recovered from the infection or living with long COVID-19.

SARS-CoV-2 induced liver injury: Incidence, risk factors, impact on COVID-19 severity and prognosis in different population groups

Liver is unlikely the key organ driving mortality in coronavirus disease 2019 (COVID-19) however, liver function tests (LFTs) abnormalities are widely observed mostly in moderate and severe cases. According to this review, the overall prevalence of abnormal LFTs in COVID-19 patients ranges from 2.5% to 96.8% worldwide. The geographical variability in the prevalence of underlying diseases is the determinant for the observed discrepancies between East and West. Multifactorial mechanisms are implicated in COVID-19-induced liver injury. Among them, hypercytokinemia with "bystander hepatitis", cytokine storm syndrome with subsequent oxidative stress and endotheliopathy, hypercoagulable state and immuno-thromboinflammation are the most determinant mechanisms leading to tissue injury. Liver hypoxia may also contribute under specific conditions, while direct hepatocyte injury is an emerging mechanism. Except for initially observed severe acute respiratory distress syndrome corona virus-2 (SARS-CoV-2) tropism for cholangiocytes, more recent cumulative data show SARS-CoV-2 virions within hepatocytes and sinusoidal endothelial cells using electron microscopy (EM). The best evidence for hepatocellular invasion by the virus is the identification of replicating SARS-CoV-2 RNA, S protein RNA and viral nucleocapsid protein within hepatocytes using in-situ hybridization and immunostaining with observed intrahepatic presence of SARS-CoV-2 by EM and by in-situ hybridization. New data mostly derived from imaging findings indicate possible long-term sequelae for the liver months after recovery, suggesting a post-COVID-19 persistent live injury.

The Intersection of COVID-19 and Metabolic-Associated Fatty Liver Disease: An Overview of the Current Evidence

The global population is currently experiencing the impact of the SARS-CoV-2 coronavirus, which has caused the Coronavirus Disease 2019 (COVID-19) pandemic. With our profound comprehension of COVID-19, encompassing the involvement sequence of the respiratory tract, gastrointestinal system, and cardiovascular apparatus, the multiorgan symptoms of this infectious disease have been discerned. Metabolic-associated fatty liver disease (MAFLD), formerly known as non-alcoholic fatty liver disease (NAFLD), is a pervasive public health concern intricately linked with metabolic dysregulation and estimated to afflict one-fourth of the global adult population. The burgeoning focus on the association between COVID-19 and MAFLD is justified by the potential role of the latter as a risk factor for both SARS-CoV-2 infection and the subsequent emergence of severe COVID-19 symptoms. Investigations have suggested that changes in both innate and adaptive immune responses among MAFLD patients may play a role in determining the severity of COVID-19. The remarkable similarities observed in the cytokine pathways implicated in both diseases imply the existence of shared mechanisms governing the chronic inflammatory responses characterizing these conditions. The effect of MAFLD on the severity of COVID-19 illness remains uncertain, as indicated by conflicting results in cohort investigations.

Features of Liver Injury in COVID-19 Pathophysiological, Biological and Clinical Particularities

The outbreak of the coronavirus pandemic in March 2020 has caused unprecedented pressure on public health and healthcare. The spectrum of COVID-19 onset is large, from mild cases with minor symptoms to severe forms with multi-organ dysfunction and death. In COVID-19, multiple organ damage has been described, including lung damage, acute kidney injury, liver damage, stroke, cardiovascular and digestive tract disorders. The aspects of liver injury are different, sometimes presenting with only a slight increase in liver enzymes, but sometimes with severe liver injury, leading to acute liver failure requiring liver transplantation. In patients with chronic liver disease, especially liver cirrhosis, immune dysfunction can increase the risk of infection. Immune dysfunction has a multifactorial physiopathological mechanism, implying a complement system and macrophage activation, lymphocyte and neutrophil activity dysfunction, and intestinal dysbiosis. This review aims to evaluate the most relevant studies published in the last years related to the etiopathogenetic, biochemical, and histological aspects of liver injury in patients diagnosed with COVID-19. Liver damage is more evident in patients with underlying chronic liver disease, with a significantly higher risk of developing severe outcomes of COVID-19 and death. Systemic inflammation, coagulation disorders, endothelial damage, and immune dysfunction explain the pathogenic mechanisms involved in impaired liver function. Although various mechanisms of action of SARS-CoV-2 on the liver cell have been studied, the impact of the direct viral effect on hepatocytes is not yet established.

Liver and Biliary Tract Disease in Patients with Coronavirus disease-2019 Infection

Coronavirus disease-2019 (COVID-19) had become a global pandemic since March 2020. Although, the most common presentation is of pulmonary involvement, hepatic abnormalities can be encountered in up to 50% of infected individuals, which may be associated with disease severity, and the mechanism of liver injury is thought to be multifactorial. Guidelines for management in patients with chronic liver disease during COVID-19 era are being regularly updated. Patients with chronic liver disease and cirrhosis, including liver transplant candidates and liver transplant recipients are strongly recommended to receive SARS-CoV-2 vaccination because it can reduce rate of COVID-19 infection, COVID-19-related hospitalization, and mortality.

Impact of chronic liver disease on SARS-CoV-2 infection outcomes: Roles of stage, etiology and vaccination

Since the first identification in December of 2019 and the fast spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, it has represented a dramatic global public health concern. Though affecting mainly the respiratory system, SARS-CoV-2 disease, defined as coronavirus disease 2019 (COVID-19), may have a systemic involvement leading to multiple organ dysfunction. Experimental evidence about the SARS-CoV-2 tropism for the liver and the increasing of hepatic cytolysis enzymes during infection support the presence of a pathophysiological relationship between liver and SARS-CoV-2. On the other side, patients with chronic liver disease have been demonstrated to have a poor prognosis with COVID-19. In particular, patients with liver cirrhosis appear extremely vulnerable to infection. Moreover, the etiology of liver disease and the vaccination status could affect the COVID-19 outcomes. This review analyzes the impact of the disease stage and the related causes on morbidity and mortality, clinical outcomes during SARS-CoV-2 infection, as well as the efficacy of vaccination in patients with chronic liver disease.

Liver injury associated with the severity of COVID-19: A meta-analysis

Background

The current 2019 novel coronavirus disease (COVID-19) pandemic is a major threat to global health. It is currently uncertain whether and how liver injury affects the severity of COVID-19. Therefore, we conducted a meta-analysis to determine the association between liver injury and the severity of COVID-19.

Methods

A systematic search of the PubMed, Embase, and Cochrane Library databases from inception to August 12, 2022, was performed to analyse the reported liver chemistry data for patients diagnosed with COVID-19. The pooled odds ratio (OR), weighted mean difference (WMD) and 95% confidence interval (95% CI) were assessed using a random-effects model. Furthermore, publication bias and sensitivity were analyzed.

Results

Forty-six studies with 28,663 patients were included. The pooled WMDs of alanine aminotransferase (WMD = 12.87 U/L, 95% CI: 10.52-15.23, I ² = 99.2%), aspartate aminotransferase (WMD = 13.98 U/L, 95% CI: 12.13-15.83, I ² = 98.2%), gamma-glutamyl transpeptidase (WMD = 20.67 U/L, 95% CI: 14.24-27.10, I ² = 98.8%), total bilirubin (WMD = 2.98 μmol/L, 95% CI: 1.98-3.99, I ² = 99.4%), and prothrombin time (WMD = 0.84 s, 95% CI: 0.46-1.23, I ² = 99.4%) were significantly higher and that of albumin was lower (WMD = -4.52 g/L, 95% CI: -6.28 to -2.75, I ² = 99.9%) in severe cases. Moreover, the pooled OR of mortality was higher in patients with liver injury (OR = 2.72, 95% CI: 1.18-6.27, I ² = 71.6%).

Conclusions

Hepatocellular injury, liver metabolic, and synthetic function abnormality were observed in severe COVID-19. From a clinical perspective, liver injury has potential as a prognostic biomarker for screening severely affected patients at early disease stages.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, Identifier: CRD42022325206.

Impact of baseline abnormal liver enzymes in the outcome of COVID-19 infection

Background

Little is known about the significance of liver function tests (LFT) abnormalities in COVID-19 and their impact on disease outcomes. The aims of the study were to evaluate abnormalities of LFT in patients with COVID-19 and their impact on disease severity, mortality, and correlation with leukocyte markers of inflammation.

Methods

All patients with COVID-19 admitted to the emergency department (ED) of a single reference center were retrospectively evaluated. Data were collected using an electronic medical database covering the following variables: demographics, baseline complete blood count (CBC) and ratios, neutrophil-lymphocyte (NLR) and monocyte-lymphocyte ratios (MLR), systemic immune-inflammation index (SII), aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels. Disease severity was defined by the presence of organ failure (OF) or requirement for intensive care unit (ICU) support. Mortality was considered as patient death during hospitalization.

Results

A total of 1,539 subjects (799 women, mean age 57±18 years) with COVID-19 were evaluated. Abnormal AST and/or ALT were seen in 50% of them, with a frequency and magnitude that significantly correlated with leukocyte count and ratios. Both LFT were significantly associated with requirement for hospital and ICU admission and mortality. High AST levels were significantly associated with the presence, number, and types of OFs and in-hospital length of stay (LOS). Elevated ALT was also significantly associated with the aforementioned variables, with the exception of OFs presence, circulatory failure and LOS.

Conclusions

LFT abnormalities are frequently seen in COVID-19 patients, reflect SARS-CoV-2 associated inflammation and may predict adverse outcomes. LFT may be useful to aid decision-making in the ED for hospital admission or scheduled outpatient reevaluation.

[Liver injury due to COVID-19 in critically ill adult patients. A retrospective study]

INTRODUCTION AND AIM

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged, causing the current pandemic of acute respiratory disease known as COVID-19. Liver injury due to COVID-19 is defined as any liver injury occurring during the course of the disease and treatment of patients with COVID-19, with or without liver disease. The incidence of elevated liver transaminases, alanine aminotransferase (ALT) and aspartate aminotransferase (AST), ranges from 2.5 to 76.3%. The aim of the present study was to describe the hepatic biochemical abnormalities, after a SARS-CoV-2-positive polymerase chain reaction (PCR) test, and the mortality rate in critically ill patients.

MATERIALS AND METHODS

A retrospective study was conducted that included 70 patients seen at a private hospital in Mexico City, within the time frame of February-December 2021. Median patient age was 44.5 years (range: 37-57.2) and 43 (61.4%) of the patients were men. Liver function tests were performed on the patients at hospital admission.

RESULTS

Gamma glutamyl transferase (GGT) levels were elevated (p = 0.032), as were those of AST (p = 0.011) and ALT (p = 0.021). The patients were stratified into age groups: 18-35, 36-50, and > 50 years of age. The 18 to 35-year-olds had the highest liver enzyme levels and transaminase levels were higher, the younger the patient. Due to the low mortality rate (one patient whose death did not coincide with a hepatic cause), the multivariate analysis showed an R2 association of 0.689, explained by AST, GGT, and C-reactive protein levels.

CONCLUSIONS

Despite the increase in transaminases in our study population during the course of COVID-19, there was no increase in mortality. Nevertheless, hospitalized patient progression should be continuously followed.

COVID-19 and liver injury: An ongoing challenge

The new coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified in December 2019, in Wuhan, China. The virus was rapidly spread worldwide, causing coronavirus disease 2019 (COVID-19) pandemic. Although COVID-19 is presented, usually, with typical respiratory symptoms (i.e., dyspnea, cough) and fever, extrapulmonary manifestations are also encountered. Liver injury is a common feature in patients with COVID-19 and ranges from mild and temporary elevation of liver enzymes to severe liver injury and, even, acute liver failure. The pathogenesis of liver damage is not clearly defined; multiple mechanisms contribute to liver disorder, including direct cytopathic viral effect, cytokine storm and immune-mediated hepatitis, hypoxic injury, and drug-induced liver toxicity. Patients with underlying chronic liver disease (i.e., cirrhosis, non-alcoholic fatty liver disease, alcohol-related liver disease, hepatocellular carcinoma, etc.) may have greater risk to develop both severe COVID-19 and further liver deterioration, and, as a consequence, certain issues should be considered during disease management. The aim of this review is to present the prevalence, clinical manifestation and pathophysiological mechanisms of liver injury in patients with SARS-CoV-2 infection. Moreover, we overview the association between chronic liver disease and SARS-CoV-2 infection and we briefly discuss the management of liver injury during COVID-19.

The pathological mechanism of the COVID-19 convalescence and its treatment with traditional Chinese medicine

The severe acute respiratory syndrome coronavirus - 2 (SARS - CoV - 2) was reported to cause the Wuhan outbreak of the corona virus disease 2019(COVID-19). To date, the COVID-19 has infected more than 600 million people gloabally. As a growing number of patients recover from acute infections and are discharged from hospitals, the proportion of patients in the recovery period is gradually increasing. Many of these individuals have been reported to experience multiple symptoms during the convalescence, such as fatigue, dyspnea and pain which are designated as "long-COVID", "post-COVID syndrome" or "recovery sequelae. We searched for recent articles published in PubMed on COVID-19 convalescence and found that the pathogenesis of COVID-19 convalescence is not yet well recognized. It may be associated with incomplete recovery of immune system, parenchymal organ damage (liver or lung), coagulation abnormalities, "second hit" caused by viral infection, and Phenomenon of Cell Senescence-Associated Secretory Phenotype (SASP). Some drugs and psychological factors of patients also play a non-negligible role in it. We also found that the effect of traditional Chinese medicine (TCM) is effective in the treatment of the COVID-19 recovery phase, which can not only relieve the corresponding symptoms, but also improve the indicators and pulmonary fibrosis. Bufei Huoxue Capsule, as the only drug explicitly mentioned for COVID-19 recovery period, can exert strong rehabilitative effects on physiological activity in patients recovering from COVID-19. In addition, in previous studies, traditional Chinese medicine has been confirmed to have the ability to resist cytokine storms, as well as improve coagulation and myocardial damage, which makes it have potential therapeutic advantages in targeting the hyperimmune response, coagulation abnormalities and myocardial damage existing in the recovery period. In conclusion, the clinical symptoms of patients convalescing from COVID-19 are complex, and its pathogenesis has not been elucidated. traditional Chinese medicine, as a traditional treatment, its specific action and mechanism need to be confirmed by more studies, so that it can play a better role.

Association of serum total bilirubin and potential predictors with mortality in acute respiratory failure: A retrospective cohort study

BACKGROUND

Total serum bilirubin (TBIL) levels are a risk factor in critically ill patients. However, the relationship between the dynamics of TBIL and the prognosis of acute respiratory failure (ARF) patients is unclear.

OBJECTIVES

This study aimed to investigate the impact of different levels of TBIL during hospitalization on mortality in ARF patients.

METHODS

This study used a retrospective cohort study. We extracted information on ARF patients from the Medical Information Bank for Intensive Care (MIMIC)-III (version 1.4). We used propensity score matching (PSM) to adjust for the level of potential baseline-level differences between groups. Cox regression was used to analyze mortality risk factors in patients with ARF. Subgroup analysis was used to explore special populations.

RESULTS

2673 patients were included in the study, and 19.7% developed hyperbilirubinemia (TBIL ≥ 2 mg/dL) during their hospitalization. After PSM, multivariate Cox regression showed a 50% and 135% increased risk of death for a maximum value of TBIL ≥ 5 mg/dL and minimum value of TBIL ≥ 2 mg/dL during hospitalization, respectively, compared to the control population. In addition, age ≥ 65 years, previous comorbid malignancies, respiratory rate ≥ 22 beats/min, SpO2 ≥ 95, BUN ≥ 20 mg/dL, lactate ≥ 5 mmol/L, platelet < 100 * 10 ^ 9/L were independent risk factors for 1-year mortality in ARF patients. Subgroup analysis showed that high bilirubin had a greater effect on patients aged less than 65 years (P for interaction < 0.05).

CONCLUSIONS

Hyper TBIL (TBIL max ≥ 5 mg/dL or TBIL min ≥ 2 mg/dL) was an independent risk factor for 1-year mortality in patients with ARF. This study suggests that clinicians should be aware of TBIL levels and intervene early in these patients.

Biomarkers Predicting Poor Prognosis in Covid-19 Patients: A Survival Analysis

Introduction With the spread of the Covid-19 pandemic and its overwhelming impact on health systems in several countries, the importance of identifying predictors of severity is of paramount importance. The objective of this study is to determine the relationship between death and the biological parameters of patients with Covid-19. Materials and methods This is an analytical retrospective cohort study conducted on 326 patients admitted to the Mohammed VI University Hospital in Oujda, Morocco. The statistical analysis concerned the biological parameters carried out on the admission of the patients, in addition to age and sex. The comparison between the two surviving and non-surviving groups was made by a simple analysis than a multivariate analysis by logistic regression. Next, a survival analysis was performed by the Kaplan-Meier method and then by Cox regression. Results A total of 326 patients were included in the study, including 108 fatal cases. The mean age was 64.66 ± 15.51 and the sex ratio was 1.08:1 (M:F). Age, procalcitonin, liver enzymes, and coagulation factors were significantly higher in patients who died of Covid-19 and are therefore considered to be the main prognostic factors identified in this study. Conclusion Knowledge and monitoring of predictive biomarkers of poor prognosis in patients with Covid-19 could be of great help in the identification of patients at risk and in the implementation of an effective diagnostic and therapeutic strategy to predict severe disease forms.

Risk of New-Onset Liver Injuries Due to COVID-19 in Preexisting Hepatic Conditions-Review of the Literature

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) impacted the world and caused the 2019 coronavirus disease (COVID-19) pandemic. The clinical manifestations of the virus can vary from patient to patient, depending on their respective immune system and comorbidities. SARS-CoV-2 can affect patients through two mechanisms: directly by targeting specific receptors or by systemic mechanisms. We reviewed data in the latest literature in order to discuss and determine the risk of new-onset liver injuries due to COVID-19 in preexisting hepatic conditions. The particular expression of angiotensin-converting enzyme 2 (ACE2) receptors is an additional risk factor for patients with liver disease. COVID-19 causes more severe forms in patients with non-alcoholic fatty liver disease (NAFLD), increases the risk of cirrhosis decompensation, and doubles the mortality for these patients. The coinfection SARS-CoV-2-viral hepatitis B or C might have different outcomes depending on the stage of the liver disease. Furthermore, the immunosuppressant treatment administered for COVID-19 might reactivate the hepatic virus. The high affinity of SARS-CoV-2 spike proteins for cholangiocytes results in a particular type of secondary sclerosing cholangitis. The impact of COVID-19 infection on chronic liver disease patients is significant, especially in cirrhosis, influencing the prognosis and outcome of these patients.

Correlation between COVID-19 and hepatitis B: A systematic review

BACKGROUND

There is growing evidence that patients with coronavirus disease 2019 (COVID-19) frequently present with liver impairment. Hepatitis B virus (HBV) remains a major public health threat in current society. Both severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and HBV can cause liver damage, and current findings on whether HBV infection increases disease severity in COVID-19 patients are inconsistent, and whether SARS-CoV-2 infection accelerates hepatitis B progression or leads to a worse prognosis in hepatitis B patients has not been adequately elucidated.

AIM

To explore the complex relationship between COVID-19 and hepatitis B in order to inform the research and management of patients co-infected with SARS-CoV-2 and HBV.

METHODS

An experienced information specialist searched the literature in the following online databases: PubMed, China National Knowledge Infrastructure, Google Scholar, Scopus, Wiley, Web of Science, Cochrane, and ScienceDirect. The literature published from December 2019 to September 1, 2022 was included in the search. We also searched medRxiv and bioRxiv for gray literature and manually scanned references of included articles. Articles reporting studies conducted in humans discussing hepatitis B and COVID-19 were included. We excluded duplicate publications. News reports, reports, and other gray literature were included if they contained quantifiable evidence (case reports, findings, and qualitative analysis). Some topics that included HBV or COVID-19 samples but did not have quantitative evidence were excluded from the review.

RESULTS

A total of 57 studies were eligible and included in this review. They were from 11 countries, of which 33 (57.9%) were from China. Forty-two of the 57 studies reported abnormalities in liver enzymes, three mainly reported abnormalities in blood parameters, four indicated no significant liver function alterations, and another eight studies did not provide data on changes in liver function. Fifty-seven studies were retrospective and the total number of co-infections was 1932, the largest sample size was 7723, and the largest number of co-infections was 353. Most of the studies suggested an interaction between hepatitis B and COVID-19, while 12 studies clearly indicated no interaction between hepatitis B and COVID-19. Six of the 57 studies clearly reported HBV activation. Six studies were related to liver transplant patients.

CONCLUSION

There is some association between COVID-19 and hepatitis B. Future high-quality randomized trials are needed to further elucidate the interaction between COVID-19 and hepatitis B.

Progressive cholestasis and associated sclerosing cholangitis are frequent complications of COVID-19 in patients with chronic liver disease

BACKGROUND AND AIMS

Cholestasis is associated with disease severity and worse outcome in COVID-19. Cases of secondary sclerosing cholangitis (SSC) after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have been described.

APPROACH AND RESULTS

Hospitalized patients with COVID-19 between 03/2020 and 07/2021 were included. Patients were stratified as having (i) no chronic liver disease (CLD), (ii) non-advanced CLD (non-ACLD), or (iii) advanced CLD (ACLD). Patients with CLD and non-COVID-19 pneumonia were matched to patients with CLD and COVID-19 as a control cohort. Liver chemistries before (Pre) and at first, second, and third blood withdrawal after SARS-CoV-2 infection (T1-T3) and at last available time point (last) were recorded. A total of 496 patients were included. In total, 13.1% (n = 65) had CLD (non-ACLD: 70.8%; ACLD: 29.2%); the predominant etiology was NAFLD/NASH (60.0%). COVID-19-related liver injury was more common among patients with CLD (24.6% vs. 10.6%; p = 0.001). After SARS-CoV-2 infection, patients with CLD exhibited progressive cholestasis with persistently increasing levels of alkaline phosphatase (Pre: 91.0 vs. T1: 121.0 vs. last: 175.0 U/L; p < 0.001) and gamma-glutamyl transferase (Pre: 95.0 vs. T1: 135.0 vs. last: 202.0 U/L; p = 0.001). A total of 23.1% of patients with CLD (n = 15/65) developed cholestatic liver failure (cholestasis plus bilirubin ≥6 mg/dl) during COVID-19, and 15.4% of patients (n = 10/65) developed SSC. SSC was significantly more frequent among patients with CLD and COVID-19 than in patients with CLD and non-COVID-19 pneumonia (p = 0.040). COVID-19-associated SSC occurred predominantly in patients with NAFLD/NASH and metabolic risk factors. A total of 26.3% (n = 5/19) of patients with ACLD experienced hepatic decompensation after SARS-CoV-2 infection.

CONCLUSIONS

About 20% of patients with CLD develop progressive cholestasis after SARS-CoV-2 infection. Patients with NAFLD/NASH and metabolic risk factors are at particular risk for developing cholestatic liver failure and/or SSC after COVID-19.

Changing Features of Liver Injury in COVID-19 Patients: Impact of Infection with the SARS-CoV-2 Delta (B.1.617.2) Variants

BACKGROUND

There is growing evidence that abnormal liver function tests (LFTs) are common in patients with coronavirus disease 2019 (COVID-19). However, it is not known whether viral involvement in the liver differs according to the strain. We investigated the impact on liver injury in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Delta (B.1.617.2) variants.

MATERIALS AND METHODS

We conducted a single-center, retrospective cohort study, including 372 patients admitted during the pre-Delta period (PDP: between February 1 and November 30, 2020) and 137 patients admitted during the Delta period (DP: between August 1 and August 31, 2021). Initial liver injury was defined as alanine aminotransferase (ALT) or aspartate aminotransferase (AST) levels ≥3 × the upper limit of normal (ULN) or alkaline phosphatase (ALP) or total bilirubin ≥2 × the ULN within 3 days from admission.

RESULTS

Of 509 patients with COVID-19 included in our study, 38 (7.5%) patients had initial liver injury. The DP group had a significantly higher rate of initial liver injury than the PDP group (PDP: 5.9% vs. DP: 11.7%, P = 0.028). The DP group (adjusted odds ratio [aOR]: 2.737, 95% confidence interval [CI]: 1.322 - 5.666) was independently associated with initial liver injury. During hospitalization, 160 (31.4%) patients had severe COVID-19. The DP group and initial liver injury had higher odds of progressing to severe COVID-19 (aOR: 2.664, 95% CI: 1.526 - 4.648, and aOR: 4.409, 95% CI: 1.816 - 10.707, respectively). The mediation analysis suggested that initial liver injury mediates the relationship between SARS-CoV-2 Delta variant infection and severe COVID-19 (unstandardized beta coefficient = 0.980, Standard error = 0.284, P = 0.001).

CONCLUSION

Initial liver injury is more common in COVID-19 patients with Delta variants. Also, Delta variants and initial liver injury are associated with poor clinical outcomes.

Liver test abnormalities in asymptomatic and mild COVID-19 patients and their association with viral shedding time

BACKGROUND

Asymptomatic infections and mild symptoms are common in patients infected with the Omicron variant, and data on liver test abnormalities are rare.

AIM

To evaluated the clinical characteristics of asymptomatic and mild coronavirus disease 2019 (COVID-19) patients with abnormal liver test results.

METHODS

This retrospective study included 661 laboratory-confirmed asymptomatic and mild COVID-19 patients who were treated in two makeshift hospitals in Ningbo from April 5, 2022 to April 29, 2022. Clinical information and viral shedding time were collected, and univariate and multivariate logistic regression models were performed in statistical analyses.

RESULTS

Of the 661 patients, 83 (12.6%) had liver test abnormalities, and 6 (0.9%) had liver injuries. Abnormal liver tests revealed a reliable correlation with a history of liver disease (P < 0.001) and a potential correlation with male sex and obesity (P < 0.05). Elevated alanine aminotransferase was reliably associated with obesity (P < 0.05) and a history of liver disease (P < 0.001). Elevated aspartate transaminase (AST) was reliably correlated with a history of liver disease (P < 0.001), and potentially correlated with age over 30 years (P < 0.05). There was a reliable correlation between AST ≥ 2× the upper limit of normal and a longer viral shedding time, especially in mild cases.

CONCLUSION

Obesity and a history of liver disease are risk factors for liver test abnormalities. Being male and an older age are potential risk factors. Attention should be given to liver tests in asymptomatic and mild COVID-19 patients, which has crucial clinical significance for evaluating the viral shedding time.

Hepatic manifestations of coronavirus disease 2019 infection: Clinical and laboratory perspective

The novel coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2, has become a global challenge of unprecedented nature since December 2019. Although most patients with COVID-19 exhibit mild clinical manifestations and upper respiratory tract involvement, in approximately 5%-10% of patients, the disease is severe and involves multiple organs, leading to multi-organ dysfunction and failure. The liver and gastrointestinal tract are also frequently involved in COVID-19. In the context of liver involvement in patients with COVID-19, many key aspects need to be addressed in both native and transplanted organs. This review focuses on the clinical presentations and laboratory abnormalities of liver function tests in patients with COVID-19 with no prior liver disease, patients with pre-existing liver diseases and liver transplant recipients. A brief overview of the history of COVID-19 and etiopathogenesis of the liver injury will also be described as a prelude to better understanding the above aspects.

COVID-19-induced liver injury in adult patients: A brief overview

Coronavirus disease has spread worldwide since 2019, causing important pandemic issues and various social health problems to date. Little is known about the origin of this virus and the effects it has on extra-pulmonary organs. The different mechanisms of the virus and the influence it has on humans are still being studied, with hopes of finding a cure for the disease and the pathologies associated with the infection. Liver damage caused by coronavirus disease 2019 (COVID-19) is sometimes underestimated and has been of important clinical interest in the past few years. Hepatic dysfunctions can manifest in different forms which can sometimes be mild and without specific signs and symptoms or be severe with important clinical implications. There are several studies that have tried to explain the mechanism of entry (hepatotropism) of the virus into hepatocytes and the effects the virus has on this important organ. What clearly emerges from the current literature is that hepatic injury represents an important clinical aspect in the management of patients infected with COVID-19, especially in frail patients and those with comorbidities. The aim of our brief overview is to summarize the current literature regarding the forms of hepatic damage, complications, mechanisms of pathology, clinical features of liver injury, influence of comorbidities and clinical management in patients with COVID-19 infection.

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.

COVID-19 associated liver injury: A general review with special consideration of pregnancy and obstetric outcomes

Liver injury is an increasingly recognized extra-pulmonary manifestation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Coronavirus disease 2019 (COVID-19) associated liver injury (COVALI) is a clinical syndrome encompassing all patients with biochemical liver injury identified in the setting of SARS-CoV-2 infection. Despite profound clinical implications, its pathophysiology is poorly understood. Unfortunately, most information on COVALI is derived from the general population and may not be applicable to individuals under-represented in research, including pregnant individuals. This manuscript reviews: Clinical features of COVALI, leading theories of COVALI, and existing literature on COVALI during pregnancy, a topic not widely explored in the literature. Ultimately, we synthesized data from the general and perinatal populations that demonstrates COVALI to be a hepatocellular transaminitis that is likely induced by systemic inflammation and that is strongly associated with disease severity and poorer clinical outcome, and offered perspective on approaching transaminitis in the potentially COVID-19 positive patient in the obstetric setting.

Clinical Outcome and Risk Assessment in Hospitalized COVID-19 Patients with Elevated Transaminases and Acute Kidney Injury: A Single Center Study

OBJECTIVES

Initial reports indicate a high incidence of abnormal aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels in patients with COVID-19 and possible association with acute kidney injury (AKI). We aimed to investigate clinical features of elevated transaminases on admission, its association with AKI, and outcomes in patients with COVID-19.

METHODS

A retrospective analysis of the registered data of hospitalized patients with laboratory-confirmed COVID-19 and assessment of the AST and ALT was performed. Multinomial logistic regression was used to determine factors associated with community-acquired AKI (CA-AKI) and hospital-acquired AKI (HA-AKI).

RESULTS

The subjects comprised 828 patients (mean age = 65.0±16.0 years; 51.4% male). Hypertension was present in 70.3% of patients, diabetes mellitus in 26.0%, and chronic kidney disease in 8.5%. In-hospital mortality was 21.0%. At admission, only 41.5% of patients had hypertransaminasemia. Patients with elevated transaminases at admission were younger, had higher levels of inflammatory markers and D-dimer, and poorer outcomes. The AKI incidence in the study population was 27.1%. Patients with hypertransaminasemia were more likely to develop AKI (33.5% vs. 23.3%, p = 0.003). Patients with predominantly elevated AST (compared to elevated ALT) were more likely to have adverse outcomes. Multinomial logistic regression found that hypertension, chronic kidney disease, elevated AST, and hematuria were associated with CA-AKI. Meanwhile, age > 65 years, hypertension, malignancy, elevated AST, and hematuria were predictors of HA-AKI.

CONCLUSIONS

Elevated transaminases on admission were associated with AKI and poor outcomes. Patients with elevated AST were more likely to have adverse outcomes. Elevated AST on admission was associated with CA-AKI and was a predictor of HA-AKI.

Liver Function Derangement in Patients with Severe Fever and Thrombocytopenia Syndrome

BACKGROUND AND AIMS

Patients with severe fever with thrombocytopenia syndrome (SFTS) commonly show liver function impairment. This study aimed to characterize the liver function indices in SFTS patients and investigate their association with mortality.

METHODS

Clinical information and laboratory results of 459 laboratory-confirmed SFTS patients, including 78 deceased and 381 surviving patients, were retrospectively analyzed. To explore the infectivity of SFTS caused by novel Bunyavirus (SFTSV) in hepatocytes, Huh7 human hepatoma cells were infected with various concentrations of SFTSV in vitro.

RESULTS

The proportion of SFTS patients developing liver injury during hospitalization was 73.2% (336/459); the hepatocellular injury was the predominant type. The median time to occurrence of liver injury from disease onset was 8 d. Liver injury in the deceased group occurred earlier than that in the surviving group. Alanine aminotransferase (ALT) level between 2-5 times upper limit of normal (ULN) at 4-6 d and between 5-15 ULN at 7-12 d of disease course were independent predictors of mortality. Alkaline phosphatase (ALP) >2 ULN at 7-9 d and elevated ALP at 10-12 days after disease onset were risk factors for death. ALT and aspartate transaminase (AST) levels were correlated with lymphocyte count and platelet-to-lymphocyte ratio (PLR). Total bilirubin (TB), ALT, AST levels showed positive correlation with viral load. In the in vitro experiment, SFTSV infected and replicated inside Huh7 cells.

CONCLUSIONS

Liver injury is common in SFTS patients. ALT and ALP were independent predictors of SFTS-related mortality. Frequent monitoring and evaluation of liver function indices are needed for SFTS patients.

A prediction model for COVID-19 liver dysfunction in patients with normal hepatic biochemical parameters

Coronavirus disease 2019 (COVID-19) patients with liver dysfunction (LD) have a higher chance of developing severe and critical disease. The routine hepatic biochemical parameters ALT, AST, GGT, and TBIL have limitations in reflecting COVID-19-related LD. In this study, we performed proteomic analysis on 397 serum samples from 98 COVID-19 patients to identify new biomarkers for LD. We then established 19 simple machine learning models using proteomic measurements and clinical variables to predict LD in a development cohort of 74 COVID-19 patients with normal hepatic biochemical parameters. The model based on the biomarker ANGL3 and sex (AS) exhibited the best discrimination (time-dependent AUCs: 0.60-0.80), calibration, and net benefit in the development cohort, and the accuracy of this model was 69.0-73.8% in an independent cohort. The AS model exhibits great potential in supporting optimization of therapeutic strategies for COVID-19 patients with a high risk of LD. This model is publicly available at https://xixihospital-liufang.shinyapps.io/DynNomapp/.

Neutrophil infiltration and myocarditis in patients with severe COVID-19: A post-mortem study

Aims

To investigate cardiac pathology in critically ill patients with coronavirus disease 2019 (COVID-19) and identify associations between pathological changes and clinical characteristics.

Methods

The present autopsy cohort study included hearts from 26 deceased patients hospitalized in intensive care units due to COVID-19, and was conducted at four sites in Wuhan, China. Cases were divided into a neutrophil infiltration group and a no-neutrophil group based on the presence or absence of histopathologically identified neutrophilic infiltrates.

Results

Among the 26 patients, histopathological examination identified active myocarditis in four patients. All patients with myocarditis exhibited extensive accompanying neutrophil infiltration, and all patients without myocarditis did not. The neutrophil infiltration group exhibited significantly higher rates of detection of interleukin-6 (100 vs. 4.6%) and tumor necrosis factor-alpha (100 vs. 31.8%) than the no-neutrophil group (both p < 0.05). On admission, four patients with neutrophil infiltration in myocardium had significantly higher baseline levels of aspartate aminotransferase, D dimer, and high-sensitivity C reactive protein than the other 22 patients (all p < 0.05). During hospitalization, patients with neutrophil infiltration had significantly higher maximum creatine kinase-MB (median 280.0 IU/L vs. 38.7 IU/L, p = 0.04) and higher troponin I (median 1.112 ng/ml vs. 0.220 ng/ml, p = 0.56) than patients without neutrophil infiltration.

Conclusion

Active myocarditis was frequently associated with neutrophil infiltration in the hearts of deceased patients with severe COVID-19. Patients with neutrophil-infiltrated myocarditis had a series of severely abnormal laboratory test results on admission, and high maximum creatine kinase-MB during hospitalization. The role of neutrophils in severe heart injury and systemic conditions in patients with COVID-19 should be emphasized.

Validation of a simple risk stratification tool for COVID-19 mortality

Risk prediction is an essential part of clinical care, in order to allocate resources and provide care appropriately. During the COVID-19 pandemic risk prediction became a matter of political and public debate as a major clinical need to guide medical and organizational decisions. We previously presented a simplified risk stratification score based on a nomogram developed in Wuhan, China in the early phase of the pandemic. Here we aimed to validate this simplified risk stratification score in a larger patient cohort from one city in Austria. Age, oxygen saturation, C-reactive protein levels and creatinine levels were used to estimate the in-hospital mortality risk for COVID-19 patients in a point based score: 1 point per age decade, 4 points for oxygen saturation <92%, 8 points for CRP > 10 mg/l and 4 points for creatinine > 84 μmol/l. Between June 2020 and March 2021, during the “second wave” of the pandemic, 1,472 patients with SARS-CoV-2 infection were admitted to two hospitals in Graz, Austria. In 961 patients the necessary dataset to calculate the simplified risk stratification score was available. In this cohort, as in the cohort that was used to develop the score, a score above 22 was associated with a significantly higher mortality (p < 0.001). Cox regression confirmed that an increase of one point in the risk stratification score increases the 28-day-mortality risk approximately 1.2-fold. Patients who were categorized as high risk (≥22 points) showed a 3–4 fold increased mortality risk. Our simplified risk stratification score performed well in a separate, larger validation cohort. We therefore propose that our risk stratification score, that contains only two routine laboratory parameter, age and oxygen saturation as variables can be a useful and easy to implement tool for COVID-19 risk stratification and beyond. The clinical usefulness of a risk prediction/stratification tool needs to be assessed prospectively (https://www.cbmed.at/covid-19-risk-calculator/).

Impact of COVID-19 on the liver and on the care of patients with chronic liver disease, hepatobiliary cancer, and liver transplantation: An updated EASL position paper

The COVID-19 pandemic has presented a serious challenge to the hepatology community, particularly healthcare professionals and patients. While the rapid development of safe and effective vaccines and treatments has improved the clinical landscape, the emergence of the omicron variant has presented new challenges. Thus, it is timely that the European Association for the Study of the Liver provides a summary of the latest data on the impact of COVID-19 on the liver and issues guidance on the care of patients with chronic liver disease, hepatobiliary cancer, and previous liver transplantation, as the world continues to deal with the consequences of the COVID-19 pandemic.

COVID-19-associated liver injury: Clinical characteristics, pathophysiological mechanisms and treatment management

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has become a global epidemic and poses a major threat to public health. In addition to COVID-19 manifesting as a respiratory disease, patients with severe disease also have complications in extrapulmonary organs, including liver damage. Abnormal liver function is relatively common in COVID-19 patients; its clinical manifestations can range from an asymptomatic elevation of liver enzymes to decompensated hepatic function, and liver injury is more prevalent in severe and critical patients. Liver injury in COVID-19 patients is a comprehensive effect mediated by multiple factors, including liver damage directly caused by SARS-CoV-2, drug-induced liver damage, hypoxia reperfusion dysfunction, immune stress and inflammatory factor storms. Patients with chronic liver disease (especially alcohol-related liver disease, nonalcoholic fatty liver disease, cirrhosis and hepatocellular carcinoma) are at increased risk of severe disease and death after infection with SARS-CoV-2, and COVID-19 aggravates liver damage in patients with chronic liver disease. This article reviews the latest SARS-CoV-2 reports, focusing on the liver damage caused by COVID-19 and the underlying mechanism, and expounds on the risk, treatment and vaccine safety of SARS-CoV-2 in patients with chronic liver disease and liver transplantation.

Predicting In-Hospital Mortality in Severe COVID-19: A Systematic Review and External Validation of Clinical Prediction Rules

Multiple prediction models for risk of in-hospital mortality from COVID-19 have been developed, but not applied, to patient cohorts different to those from which they were derived. The MEDLINE, EMBASE, Scopus, and Web of Science (WOS) databases were searched. Risk of bias and applicability were assessed with PROBAST. Nomograms, whose variables were available in a well-defined cohort of 444 patients from our site, were externally validated. Overall, 71 studies, which derived a clinical prediction rule for mortality outcome from COVID-19, were identified. Predictive variables consisted of combinations of patients′ age, chronic conditions, dyspnea/taquipnea, radiographic chest alteration, and analytical values (LDH, CRP, lymphocytes, D-dimer); and markers of respiratory, renal, liver, and myocardial damage, which were mayor predictors in several nomograms. Twenty-five models could be externally validated. Areas under receiver operator curve (AUROC) in predicting mortality ranged from 0.71 to 1 in derivation cohorts; C-index values ranged from 0.823 to 0.970. Overall, 37/71 models provided very-good-to-outstanding test performance. Externally validated nomograms provided lower predictive performances for mortality in their respective derivation cohorts, with the AUROC being 0.654 to 0.806 (poor to acceptable performance). We can conclude that available nomograms were limited in predicting mortality when applied to different populations from which they were derived.

Effects of Hepatitis B Virus Infection on Patients with COVID-19: A Meta-Analysis

BACKGROUND

The COVID-19 pandemic has brought new problems to patients infected with hepatitis B virus (HBV).

AIM

We aim to know the effects of HBV infection on patients with COVID-19.

METHODS

We searched PubMed, Embase, and Web of Science for data and utilized Stata 14.0 software for this meta-analysis with a random-effects model. This paper was conducted in alignment with the preferred reporting items for systematic review and meta-analysis (PRISMA) guideline.

RESULTS

In total, 37,696 patients were divided into two groups: 2591 COVID-19 patients infected with HBV in the experimental group and 35,105 COVID-19 patients not infected with HBV in the control group. Our study showed that the in-hospital mortality of the experimental group was significant higher than that of the control group (OR = 2.04, 95% CI 1.49-2.79). We also found that COVID-19 patients infected with HBV were more likely to develop severe disease (OR = 1.90, 95% CI 1.32-2.73) than COVID-19 patients not infected with HBV. Upon measuring alanine aminotransferase (SMD = 0.62, 95% CI 0.25-0.98), aspartate aminotransferase (SMD = 0.60, 95% CI 0.30-0.91), total bilirubin (SMD = 0.45, 95% CI 0.23-0.67), direct bilirubin (SMD = 0.36, 95% CI 0.24-0.47), lactate dehydrogenase (SMD = 0.32, 95% CI 0.18-0.47), we found that HBV infection led to significantly higher laboratory results in COVID-19 patients.

CONCLUSION

COVID-19 patients infected with HBV should receive more attention, and special attention should be given to various liver function indices during treatment.

Clinical Characteristics, Complications, and Predictors of Poor Outcome Among Hospitalized Adult COVID-19 Patients: A Retrospective Cohort Study

Background

Many international studies have reported the outcomes and predictors of coronavirus disease 2019 (COVID-19); however, only a few national studies have reported predictors of poor outcomes among adult hospitalized patients with COVID-19. Therefore, this study aimed to describe the clinical characteristics and complications of COVID-19 and identify predictors of poor outcomes.

Methods

This was a retrospective cohort study. All adult patients confirmed with COVID-19 who were admitted at the King Abdulaziz Medical City (KAMC)-Jeddah between March 1, 2020, and December 31, 2020, were included; pediatric and pregnant patients were excluded. The clinical features and complications of COVID-19 were tested for association with poor outcomes (intensive care unit [ICU] admission or death) using chi-square and Fisher’s exact tests. In addition, logistic regression analysis was performed to identify the predictors of poor outcomes.

Results

A total of 527 patients were included in this study. Forty-two patients (8%) (6-10, 95% confidence interval [CI]) died: 13 in the general wards and 29 in the ICU. Of the 84 patients admitted to the ICU, 65 underwent invasive mechanical ventilation. Poor outcome affected 97 patients (18%) (15-22, 95% CI). Shortness of breath, oxygen saturation <92%, and abnormal chest x-ray findings were associated with poor outcomes (P-value < 0.001). In addition, lymphocyte counts were significantly lower, while c-reactive protein levels were significantly higher among patients with poor outcomes (P-value < 0.001). The most common complications were acute cardiac (83 patients, 16%), acute kidney (78 patients, 15%), and liver injuries (76 patients, 14%). Predictors of poor outcome were the updated Charlson comorbidity index (CCI) (odds ratio [OR] 1.2 [95% CI 1.1-1.4]), liver injury (OR 2.6 [95% CI 1.3-4.9]), acute kidney injury (OR 4.3 [95% CI 2.3-7.8]), and acute cardiac injury (OR 5.1 [95% CI 2.8-9.4]).

Conclusions

COVID-19 disease is associated with significant morbidity and mortality. Predictors of poor outcomes among COVID-19 hospitalized patients were the updated CCI, liver injury, acute kidney, and acute myocardial injuries. Subsequently, the risk of poor COVID-19 outcomes is increased among patients with multiple comorbidities and/or multiple COVID-19 complications.

Effect of COVID-19 on Serum Activity of Liver Enzymes: Is This Associated with Severity and Mortality Rate?

Introduction Coronavirus disease 2019 (COVID-19) is a viral infection caused by a novel coronavirus known as the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The disease raises an enormous public health challenge for the international community. Liver enzymes have been reported to be frequently elevated in hospitalized patients with severe COVID-19 disease.

Materials and Methods This article is a narrative review of abnormal liver tests and liver injury as a manifestation of progression to severe pneumonia. We collected data from the PubMed database (National Library of Medicine, Bethesda, Maryland, United States). We used the search term “abnormal liver test” and relevant records were measured. The review article was organized thematically.

Results This narrative review aims to summarize the available clinical data on abnormal liver enzymes in coronavirus infection and its association with the risk of mortality, severer pneumonia, and systemic inflammation. Some clinical studies refer to abnormal liver tests and liver injury as a manifestation of progression to severe pneumonia. Recent research verified the relationship between hepatic liver enzyme activities and liver damage in patients with COVID-19, which suggested that it might reflect the infection severity and the mortality risk. Thus, this review investigated the correlation between liver serum enzymes level and the severity of COVID-19 patients, by reviewing investigating the relationship between the illness severity in COVID-19 patients with abnormal liver tests, liver pathology, and markers of inflammation.

Conclusion In the current pandemic of SARS-CoV-2, abnormalities of liver enzyme tests were commonly observed in patients with COVID-19. However, because of multiorgan damages that observed in COVID-19 patients, various issues should be considered such as the pathology and pathophysiology of the liver tissue, especially on the activation process of the immune response and cytokine storm to prevent the severity of the disease.

Liver Function Tests in COVID-19: Assessment of the Actual Prognostic Value

Deviations in laboratory tests assessing liver function in patients with COVID-19 are frequently observed. Their importance and pathogenesis are still debated. In our retrospective study, we analyzed liver-related parameters: aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), gamma-glutamyltransferase (GGT), total bilirubin (TBIL), albumin, comorbidities and other selected potential risk factors in patients admitted with SARS-CoV-2 infection to assess their prognostic value for intensive care unit admission, mechanical ventilation necessity and mortality. We compared the prognostic effectiveness of these parameters separately and in pairs to the neutrophil-to-lymphocyte ratio (NLR) as an independent risk factor of in-hospital mortality, using the Akaike Information Criterion (AIC). Data were collected from 2109 included patients. We created models using a sample with complete laboratory tests n = 401 and then applied them to the whole studied group excluding patients with missing singular variables. We estimated that albumin may be a better predictor of the COVID-19-severity course compared to NLR, irrespective of comorbidities (p < 0.001). Additionally, we determined that hypoalbuminemia in combination with AST (OR 1.003, p = 0.008) or TBIL (OR 1.657, p = 0.001) creates excellent prediction models for in-hospital mortality. In conclusion, the early evaluation of albumin levels and liver-related parameters may be indispensable tools for the early assessment of the clinical course of patients with COVID-19.

COVID-19 Pandemic: Insights into Interactions between SARS-CoV-2 Infection and MAFLD

COVID-19, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has become an ongoing global health pandemic. Since 2019, the pandemic continues to cast a long shadow on all aspects of our lives, bringing huge health and economic burdens to all societies. With our in-depth understanding of COVID-19, from the initial respiratory tract to the later gastrointestinal tract and cardiovascular systems, the multiorgan involvement of this infectious disease has been discovered. Metabolic dysfunction-associated fatty liver disease (MAFLD), formerly named nonalcoholic fatty liver disease (NAFLD), is a major health issue closely related to metabolic dysfunctions, affecting a quarter of the world's adult population. The association of COVID-19 with MAFLD has received increasing attention, as MAFLD is a potential risk factor for SARS-CoV-2 infection and severe COVID-19 symptoms. In this review, we provide an update on the interactions between COVID-19 and MAFLD and its underlying mechanisms.

Twelve Months with COVID-19: What Gastroenterologists Need to Know

Corona virus disease-19 (COVID-19) is the latest global pandemic. COVID-19 is mainly transmitted through respiratory droplets and, apart from respiratory symptoms, patients often present with gastrointestinal symptoms and liver involvement. Given the high percentage of COVID-19 patients that present with gastrointestinal symptoms (GIS), in this review, we report a practical up-to-date reference for the physician in their clinical practice with patients affected by chronic gastrointestinal (GI) diseases (inflammatory bowel disease, coeliac disease, chronic liver disease) at the time of COVID-19. First, we summarised data on the origin and pathogenetic mechanism of SARS-CoV-2. Then, we performed a literature search up to December 2020 examining clinical manifestations of GI involvement. Next, we illustrated and summarised the most recent guidelines on how to adhere to GI procedures (endoscopy, liver biopsy, faecal transplantation), maintaining social distance and how to deal with immunosuppressive treatment. Finally, we focussed on some special conditions such as faecal-oral transmission and gut microbiota. The rapid accumulation of information relating to this condition makes it particularly essential to revise the literature to take account of the most recent publications for medical consultation and patient care.

COVID-19'da hastane içi mortaliteyi tahmin etmede enflamatuvar temelli parametrelerin ve MELD-XI skorunun 4C mortalite skoru ile karşılaştırılması

Purpose: In this study, we compared the roles of inflammatory parameters such as neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), C-reactive protein/lymphocyte ratio (CLR), monocyte/lymphocyte ratio (MLR), neutrophil/platelet ratio (NPR), neutrophil/monocyte ratio (NMR), CRP/albumin ratio (CAR), BUN/albumin ratio (BAR), MELD-XI score and 4C mortality score in predicting in-hospital mortality risk in COVID-19. Materials and Methods: A total of 117 patients over 18 years old with a PCR-confirmed diagnosis of COVID-19 between June 2020 and February 2021 were retrospectively included. The roles of parameters for independently predicting in-hospital mortality were determined and compared with each other using appropriate statistical methods. Results: Age, chronic kidney disease, diabetes mellitus, acute kidney injury, and length of hospital stay, urea, creatinine, LDH, AST, ferritin, D-dimer, CRP, albumin, Hb, CLR, BAR, CAR, MELD-XI score, and 4C mortality score were significantly correlated to in-hospital mortality. However, only the 4C mortality score and AST independently predicted in-hospital mortality in COVID-19 [OR 2.08 (%95 CI 1.06-2.36), for 4C mortality score, and OR 1.05 (%95 CI 1.00-1.10), for AST]. Conclusion: Unlike other mortality-related inflammatory parameters, the 4C mortality score and AST were independent and strong predictors of mortality in hospitalized COVID-19 patients.