Primary biliary cholangitis and SARS-CoV-2 infection: incidence, susceptibility and outcomes

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

AIM

To determine the impact of liver fibrosis on the prognosis of COVID and the liver injury associated with the infection.

METHODS

Retrospective multicenter study including 575 patients requiring admission for COVID-19 between January and June 2020. FIB-4 was calculated within 6 months prior to infection and at 6 months post-infection.

RESULTS

Baseline FIB-4 was increased in patients who died (1.91±0.95 vs. 1.43±0.85; p<0.001). In addition, the 17.1% (32/187) of patients with baseline FIB-4<1.45 died versus 52.9% (9/17) if FIB-4>3.25 (p<0.001). In the adjusted multivariate analysis, baseline FIB-4 (OR 1.61 (95%CI 1.19-2.18); p=0.002) was independently associated with mortality. Parameters associated with liver injury, including AST (28±10 vs. 45±56IU/L; p<0.001) and ALT (20±12 vs. 38±48IU/L; p<0.001) were significantly higher at admission compared to baseline. Also, FIB-4 was increased from baseline to the time of admission (1.53±0.88 vs. 2.55±1.91; p<0.001), and up to 6.9% (10/145) of patients with FIB-4<1.45 at admission died versus 47.5% if FIB-4>3.25 (58/122) (p<0.001). In the adjusted multivariate analysis, FIB-4 at admission (OR 1.14 (95%CI 1.03-1.27); p=0.015) was independently associated with mortality. Also, AST (42±38 vs. 22±17IU/L; p<0.001) and ALT (40±50 vs. 20±19 IU/L; p<0.001) were significantly reduced at 6 months after the resolution of infection. Accordingly, FIB-4 decreased significantly (2.12±1.25 vs. 1.32±0.57; p<0.001) six months after the infection.

CONCLUSION

Increased FIB-4, either at baseline or at the time of admission, was related to the severity and mortality related to SARS-CoV-2 infection. However, the liver damage expressed by elevated transaminases and FIB-4 was reversible in most of patients.

Exploring the impact of ursodeoxycholic acid therapy on COVID-19 in a real-word setting

Recent data suggest that ursodeoxycholic acid (UDCA) therapy may reduce susceptibility to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and even improve clinical outcomes when coronavirus disease-2019 (COVID-19) was diagnosed. However, clinical evidence of UDCA's ability to prevent severe forms of COVID-19 remains limited and contradictory. We evaluated the association between UDCA exposure and the risk of hospitalization for COVID-19 in a large multicenter population of patients with chronic liver disease (CLD) followed during the pandemic period before vaccination. An exposed/unexposed cohort study and a nested case-control study were performed. The primary endpoint was severe COVID-19, defined as SARS-CoV2 infection requiring hospitalization. The secondary endpoint was COVID-19-associated intensive care unit (ICU) admission or death. Adjusted odds ratios (aOR) and their confidence intervals (CI) were determined after controlling for age, gender, comorbidities at risk for COVID-19, severity of CLD, and prior hospitalizations. A total of 10 147 patients, including 1322 exposed and 8825 not exposed to UDCA, totaling 21 867 person-years of follow-up, were included in the cohort analysis, while 88 patients hospitalized for COVID-19 and 840 matched controls were eligible for the nested case-control analysis. In both analyses, exposure to UDCA was not associated with a significant reduction in the risk of hospitalization for COVID-19, with aOR (95% confidence interval) values of 0.48 (0.20-1.19) and 0.93 (0.26-3.29), respectively. Furthermore, there was no significant reduction in the risk of ICU admission or death. In this large population of patients with CLD, UDCA exposure was not associated with a reduced risk of severe COVID-19.

SARS-CoV-2 Gut-Targeted Epitopes: Sequence Similarity and Cross-Reactivity Join Together for Molecular Mimicry

The gastrointestinal tract can be heavily infected by SARS-CoV-2. Being an auto-immunogenic virus, SARS-CoV-2 represents an environmental factor that might play a role in gut-associated autoimmune diseases. However, molecular mimicry between the virus and the intestinal epitopes is under-investigated. The present study aims to elucidate sequence similarity between viral antigens and human enteric sequences, based on known cross-reactivity. SARS-CoV-2 epitopes that cross-react with human gut antigens were explored, and sequence alignment was performed against self-antigens implicated in enteric autoimmune conditions. Experimental SARS-CoV-2 epitopes were aggregated from the Immune Epitope Database (IEDB), while enteric antigens were obtained from the UniProt Knowledgebase. A Pairwise Local Alignment tool, EMBOSS Matcher, was employed for the similarity search. Sequence similarity and targeted cross-reactivity were depicted between 10 pairs of immunoreactive epitopes. Similar pairs were found in four viral proteins and seven enteric antigens related to ulcerative colitis, primary biliary cholangitis, celiac disease, and autoimmune hepatitis. Antibodies made against the viral proteins that were cross-reactive with human gut antigens are involved in several essential cellular functions. The relationship and contribution of those intestinal cross-reactive epitopes to SARS-CoV-2 or its potential contribution to gut auto-immuno-genesis are discussed.

Ursodeoxycholic acid is associated with a reduction in SARS-CoV-2 infection and reduced severity of COVID-19 in patients with cirrhosis

BACKGROUND AND AIMS

Studies have demonstrated that reducing farnesoid X receptor activity with ursodeoxycholic acid (UDCA) downregulates angiotensin-converting enzyme in human lung, intestinal and cholangiocytes organoids in vitro, in human lungs and livers perfused ex situ, reducing internalization of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) into the host cell. This offers a potential novel target against coronavirus disease 2019 (COVID-19). The objective of our study was to compare the association between UDCA exposure and SARS-CoV-2 infection, as well as varying severities of COVID-19, in a large national cohort of participants with cirrhosis.

METHODS

In this retrospective cohort study among participants with cirrhosis in the Veterans Outcomes and Costs Associated with Liver cohort, we compared participants with exposure to UDCA, with a propensity score (PS) matched group of participants without UDCA exposure, matched for clinical characteristics, and vaccination status. The outcomes included SARS-CoV-2 infection, symptomatic, at least moderate, severe, or critical COVID-19, and COVID-19-related death.

RESULTS

We compared 1607 participants with cirrhosis who were on UDCA, with 1607 PS-matched controls. On multivariable logistic regression, UDCA exposure was associated with reduced odds of developing SARS-CoV-2 infection (adjusted odds ratio [aOR] 0.54, 95% confidence interval [CI] 0.41-0.71, p < 0.0001). Among patients who developed COVID-19, UDCA use was associated with reduced disease severity, including symptomatic COVID-19 (aOR 0.54, 95% CI 0.39-0.73, p < 0.0001), at least moderate COVID-19 (aOR 0.51, 95% CI 0.32-0.81, p = 0.005), and severe or critical COVID-19 (aOR 0.48, 95% CI 0.25-0.94, p = 0.03).

CONCLUSIONS

In participants with cirrhosis, UDCA exposure was associated with both a decrease in SARS-CoV-2 infection, and reduction in symptomatic, at least moderate, and severe/critical COVID-19.

Outcomes of COVID-19 among patients with liver disease

Coronavirus disease 2019 (COVID-19) is primarily a respiratory disease with multi-organ involvement, including impaired liver function. It has been noticed that a significant proportion of COVID-19 patients have liver dysfunction, especially those with a more severe disease course. The coronavirus causes direct damage to the liver using the angiotensin-converting enzyme 2, a cell-surface receptor for cellular entry, that is expressed in the liver. According to previous research, liver enzyme abnormalities were observed in a considerable proportion of COVID-19 patients, and elevated liver transaminases were found in about 20% of these patients, alkaline phosphatase in 6.1%, and gamma-glutamyl transferase in 21.1%. COVID-19 might trigger a deterioration of liver function in patients with pre-existing chronic liver diseases (CLDs) and also in those without previous liver disorders. The majority of COVID-19 patients who develop liver injury are men, the elderly, and those with a higher body mass index. Compared to the general population, COVID-19 is associated with significant morbidity and mortality in patients with liver disease (cirrhosis and liver transplantation recipients). However, some studies indicate that CLDs have a lesser role in determining patient progression towards higher disease severity.

Protective effect of ursodeoxycholic acid on COVID-19 in patients with chronic liver disease

Objective

Ursodeoxycholic acid (UDCA) may reduce susceptibility to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection by downregulating angiotensin-converting enzyme 2 (ACE2), based on recent experimental investigation. This study aimed to determine the potential protective effect of UDCA against SARS-CoV-2 infection in patients with chronic liver disease.

Methods

Patients with chronic liver disease receiving UDCA (taking UDCA ≥1 month) at Beijing Ditan Hospital between January 2022 and December 2022 were consecutively enrolled. These patients were matched in a 1:1 ratio to those with liver disease not receiving UDCA during the same period by using a propensity score matching analysis with nearest neighbor matching algorithm. We conducted a phone survey of coronavirus disease 2019 (COVID-19) infection during the early phase of the pandemic liberation (from 15 December 2022 to 15 January 2023). The risk of COVID-19 was compared in two matched cohorts of 225 UDCA users and 225 non-UDCA users based on patient self-report.

Results

In the adjusted analysis, the control group was superior to the UDCA group in COVID-19 vaccination rates and liver function indicators, including γ-glutamyl transpeptidase and alkaline phosphatase (p < 0.05). UDCA was associated with a lower incidence of SARS-CoV-2 infection (UDCA 85.3% vs. control 94.2%, p = 0.002), more mild cases (80.0% vs. 72.0%, p = 0.047), and shorter median time from infection to recovery (5 vs. 7 days, p < 0.001). Logistic regression analysis showed that UDCA was a significant protective factor against COVID-19 infection (OR: 0.32, 95%CI: 0.16-0.64, p = 0.001). Furthermore, diabetes mellitus (OR: 2.48, 95%CI: 1.11-5.54, p = 0.027) and moderate/severe infection (OR: 8.94, 95%CI: 1.07-74.61, p = 0.043) were more likely to prolong the time from infection to recovery.

Conclusion

UDCA therapy may be beneficial in reducing COVID-19 infection risk, alleviating symptoms, and shortening the recovery time in patients with chronic liver disease. However, it should be emphasized that the conclusions were based on patient self-report rather than classical COVID-19 detection by experimental investigations. Further large clinical and experimental studies are needed to validate these findings.

COVID-19 and liver disease

Knowledge on SARS-CoV-2 infection and its resultant COVID-19 in liver diseases has rapidly increased during the pandemic. Hereby, we review COVID-19 liver manifestations and pathophysiological aspects related to SARS-CoV-2 infection in patients without liver disease as well as the impact of COVID-19 in patients with chronic liver disease (CLD), particularly cirrhosis and liver transplantation (LT). SARS-CoV-2 infection has been associated with overt proinflammatory cytokine profile, which probably contributes substantially to the observed early and late liver abnormalities. CLD, particularly decompensated cirrhosis, should be regarded as a risk factor for severe COVID-19 and death. LT was impacted during the pandemic, mainly due to concerns regarding donation and infection in recipients. However, LT did not represent a risk factor per se of worse outcome. Even though scarce, data regarding COVID-19 specific therapy in special populations such as LT recipients seem promising. COVID-19 vaccine-induced immunity seems impaired in CLD and LT recipients, advocating for a revised schedule of vaccine administration in this population.

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.