Sex disparities in COVID-19 outcomes of inpatients with diabetes: insights from the CORONADO study

Risk phenotypes of diabetes and association with COVID-19 severity and death: an update of a living systematic review and meta-analysis

AIMS/HYPOTHESIS

To provide a systematic overview of the current body of evidence on high-risk phenotypes of diabetes associated with COVID-19 severity and death.

METHODS

This is the first update of our recently published living systematic review and meta-analysis. Observational studies investigating phenotypes in individuals with diabetes and confirmed SARS-CoV-2 infection with regard to COVID-19-related death and severity were included. The literature search was conducted from inception up to 14 February 2022 in PubMed, Epistemonikos, Web of Science and the COVID-19 Research Database and updated using PubMed alert to 1 December 2022. A random-effects meta-analysis was used to calculate summary relative risks (SRRs) with 95% CIs. The risk of bias was evaluated using the Quality in Prognosis Studies (QUIPS) tool and the certainty of evidence using the GRADE approach.

RESULTS

A total of 169 articles (147 new studies) based on approximately 900,000 individuals were included. We conducted 177 meta-analyses (83 on COVID-19-related death and 94 on COVID-19 severity). Certainty of evidence was strengthened for associations between male sex, older age, blood glucose level at admission, chronic insulin use, chronic metformin use (inversely) and pre-existing comorbidities (CVD, chronic kidney disease, chronic obstructive pulmonary disease) and COVID-19-related death. New evidence with moderate to high certainty emerged for the association between obesity (SRR [95% CI] 1.18 [1.04, 1.34], n=21 studies), HbA1c (53-75 mmol/mol [7-9%]: 1.18 [1.06, 1.32], n=8), chronic glucagon-like peptide-1 receptor agonist use (0.83 [0.71, 0.97], n=9), pre-existing heart failure (1.33 [1.21, 1.47], n=14), pre-existing liver disease (1.40 [1.17, 1.67], n=6), the Charlson index (per 1 unit increase: 1.33 [1.13, 1.57], n=2), high levels of C-reactive protein (per 5 mg/l increase: 1.07 [1.02, 1.12], n=10), aspartate aminotransferase level (per 5 U/l increase: 1.28 [1.06, 1.54], n=5), eGFR (per 10 ml/min per 1.73 m2 increase: 0.80 [0.71, 0.90], n=6), lactate dehydrogenase level (per 10 U/l increase: 1.03 [1.01, 1.04], n=7) and lymphocyte count (per 1×109/l increase: 0.59 [0.40, 0.86], n=6) and COVID-19-related death. Similar associations were observed between risk phenotypes of diabetes and severity of COVID-19, with some new evidence on existing COVID-19  vaccination status (0.32 [0.26, 0.38], n=3), pre-existing hypertension (1.23 [1.14, 1.33], n=49), neuropathy and cancer, and high IL-6 levels. A limitation of this study is that the included studies are observational in nature and residual or unmeasured confounding cannot be ruled out.

CONCLUSIONS/INTERPRETATION

Individuals with a more severe course of diabetes and pre-existing comorbidities had a poorer prognosis of COVID-19 than individuals with a milder course of the disease.

REGISTRATION

PROSPERO registration no. CRD42020193692.

PREVIOUS VERSION

This is a living systematic review and meta-analysis. The previous version can be found at https://link.springer.com/article/10.1007/s00125-021-05458-8 FUNDING: The German Diabetes Center (DDZ) is funded by the German Federal Ministry of Health and the Ministry of Culture and Science of the State North Rhine-Westphalia. This study was supported in part by a grant from the German Federal Ministry of Education and Research to the German Center for Diabetes Research (DZD).

Effects of Biological Sex and Pregnancy on SARS-CoV-2 Pathogenesis and Vaccine Outcomes

SARS-CoV-2 is the causative agent of COVID-19 in humans and has resulted in the death of millions of people worldwide. Similar numbers of infections have been documented in males and females; males, however, are more likely than females to be hospitalized, require intensive care unit, or die from COVID-19. The mechanisms that account for this are multi-factorial and are likely to include differential expression of ACE2 and TMPRSS2 molecules that are required for viral entry into hosts cells and sex differences in the immune response, which are due to modulation of cellular functions by sex hormones and differences in chromosomal gene expression. Furthermore, as comorbidities are also associated with poorer outcomes to SARS-CoV-2 infection and several comorbidities are overrepresented in males, these are also likely to contribute to the observed sex differences. Despite their relative better prognosis following infection with SARS-CoV-2, females do have poorer outcomes during pregnancy. This is likely to be due to pregnancy-induced changes in the immune system that adversely affect viral immunity and disruption of the renin-angiotensin system. Importantly, vaccination reduces the severity of disease in males and females, including pregnant females, and there is no evidence that vaccination has any adverse effects on the outcomes of pregnancy.

Sex differences in determinants of COVID-19 severe outcomes - findings from the National COVID Cohort Collaborative (N3C)

OBJECTIVE

The impact of comorbidities and biomarkers on COVID-19 severity vary by sex but have not yet been verified in population-based studies. We examined the association of comorbidities, inflammatory biomarkers, and severe outcomes in men and women hospitalized for COVID-19.

DESIGN

This is a retrospective cohort analysis based on the National COVID Cohort Collaborative (N3C). We included 574,391 adult patients admitted for COVID-19 at hospitals or emergency rooms between 01/01/2020 and 12/31/2021.

METHODS

We defined comorbidities at or before the first admission for COVID-19 by Charlson Comorbidity Index (CCI) and CCI components. We used the averaged lab values taken within 15 days before or after the admission date to measure biomarkers including c-reactive protein (CRP), ferritin, procalcitonin, N-terminal pro b-type natriuretic peptide (NT proBNP), d-dimer, absolute lymphocyte counts, absolute neutrophil counts, and platelets. Our primary outcome was all-cause mortality; secondary outcomes were invasive mechanical ventilation (IMV) and hospital length of stay (LOS). We used logistic regression adjusted for age, race, ethnicity, visit type, and medications to assess the association of comorbidities, biomarkers, and mortality disaggregating by sex.

RESULTS

Moderate to severe liver disease, renal disease, metastatic solid tumor, and myocardial infarction were the top four fatal comorbidities among patients who were hospitalized for COVID-19 (adjusted odds ratio [aOR] > 2). These four comorbid conditions remained the most lethal in both sexes, with a higher magnitude of risk in women than in men (p-interaction < 0.05). Abnormal elevations of CRP, ferritin, procalcitonin, NT proBNP, neutrophil, and platelet counts, and lymphocytopenia were significantly associated with the risk of death, with procalcitonin and NT proBNP as the strongest predictors (aOR > 2). The association between the abnormal biomarkers and death was stronger in women than in men (p-interaction < 0.05).

CONCLUSION

There are sex differences in inpatient mortality associated with comorbidities and biomarkers. The significant impact of these clinical determinants in women with COVID-19 may be underappreciated as previous studies stressed the increased death rate in male patients that is related to comorbidities or inflammation. Our study highlights the importance and the need for sex-disaggregated research to understand the risk factors of poor outcomes and health disparities in COVID-19.

Sex differences in comorbidities and COVID-19 mortality-Report from the real-world data

Background

The differential effect of comorbidities on COVID-19 severe outcomes by sex has not been fully evaluated.

Objective

To examine the association of major comorbidities and COVID-19 mortality in men and women separately.

Methods

We performed a retrospective cohort analysis using a large electronic health record (EHR) database in the U.S. We included adult patients with a clinical diagnosis of COVID-19 who also had necessary information on demographics and comorbidities from January 1, 2016 to October 31, 2021. We defined comorbidities by the Charlson Comorbidity Index (CCI) using ICD-10 codes at or before the COVID-19 diagnosis. We conducted logistic regressions to compare the risk of death associated with comorbidities stratifying by sex.

Results

A total of 121,342 patients were included in the final analysis. We found significant sex differences in the association between comorbidities and COVID-19 death. Specifically, moderate/severe liver disease, dementia, metastatic solid tumor, and heart failure and the increased number of comorbidities appeared to confer a greater magnitude of mortality risk in women compared to men.

Conclusions

Our study suggests sex differences in the effect of comorbidities on COVID-19 mortality and highlights the importance of implementing sex-specific preventive or treatment approaches in patients with COVID-19.

Sex Differences in COVID-19 Hospitalization and Hospital Mortality among Patients with COPD in Spain: A Retrospective Cohort Study

(1) Background: We aimed to assess the effect of COPD in the incidence of hospital admissions for COVID-19 and on the in-hospital mortality (IHM) according to sex. (2) Methods: We used national hospital discharge data to select persons aged ≥40 years admitted to a hospital with a diagnosis of COVID-19 in 2020 in Spain. (3) Results: The study population included 218,301 patients. Age-adjusted incidence rates of COVID-19 hospitalizations for men with and without COPD were 10.66 and 9.27 per 1000 persons, respectively (IRR 1.14; 95% CI 1.08−1.20; p < 0.001). The IHM was higher in men than in women regardless of the history of COPD. The COPD was associated with higher IHM among women (OR 1.09; 95% CI 1.01−1.22) but not among men. The COPD men had a 25% higher risk of dying in the hospital with COVID-19 than women with COPD (OR 1.25, 95% CI 1.1−1.42). (4) Conclusions: Sex differences seem to exist in the effect of COPD among patients suffering COVID-19. The history of COPD increased the risk of hospitalization among men but not among women, and COPD was only identified as a risk factor for IHM among women. In any case, we observed that COPD men had a higher mortality than COPD women. Understanding the mechanisms underlying these sex differences could help predict the patient outcomes and inform clinical decision making to facilitate early treatment and disposition decisions.

Higher premorbid serum testosterone predicts COVID-19-related mortality risk in men

Objective

Men are at greater risk from COVID-19 than women. Older, overweight men, and those with type 2 diabetes, have lower testosterone concentrations and poorer COVID-19-related outcomes. We analysed the associations of premorbid serum testosterone concentrations, not confounded by the effects of acute SARS-CoV-2 infection, with COVID-19-related mortality risk in men.

Design

This study is a United Kingdom Biobank prospective cohort study of community-dwelling men aged 40-69 years.

Methods

Serum total testosterone and sex hormone-binding globulin (SHBG) were measured at baseline (2006-2010). Free testosterone values were calculated (cFT). the incidence of SARS-CoV-2 infections and deaths related to COVID-19 were ascertained from 16 March 2020 to 31 January 2021 and modelled using time-stratified Cox regression.

Results

In 159 964 men, there were 5558 SARS-CoV-2 infections and 438 COVID-19 deaths. Younger age, higher BMI, non-White ethnicity, lower educational attainment, and socioeconomic deprivation were associated with incidence of SARS-CoV-2 infections but total testosterone, SHBG, and cFT were not. Adjusting for potential confounders, higher total testosterone was associated with COVID-19-related mortality risk (overall trend P = 0.008; hazard ratios (95% CIs) quintile 1, Q1 vs Q5 (reference), 0.84 (0.65-1.12) Q2:Q5, 0.82 (0.63-1.10); Q3:Q5, 0.80 (0.66-1.00); Q4:Q5, 0.82 (0.75-0.93)). Higher SHBG was also associated with COVID-19 mortality risk (P = 0.008), but cFT was not (P = 0.248).

Conclusions

Middle-aged to older men with the highest premorbid serum total testosterone and SHBG concentrations are at greater risk of COVID-19-related mortality. Men could be advised that having relatively high serum testosterone concentrations does not protect against future COVID-19-related mortality. Further investigation of causality and potential underlying mechanisms is warranted.

Sex Differences in Clinical Characteristics and Outcomes of Patients with SARS-CoV-2-Infection Admitted to Intensive Care Units in Austria

Importance: A male predominance is reported in hospitalised patients with COVID-19 alongside a higher mortality rate in men compared to women. Objective: To assess if the reported sex bias in the COVID-19 pandemic is validated by analysis of a subset of patients with severe disease. Design: A nationwide retrospective cohort study was performed using the Austrian National COVID Database. We performed a sex-specific Lasso regression to select the covariates best explaining the outcomes of mechanical ventilation and death using variables known before ICU admission. We use logistic regression to construct a sex-specific “risk score” for the outcomes using these variables. Setting: We studied the characteristics and outcomes of patients admitted to intensive care units (ICUs) in Austria. Participants: 5118 patients admitted to the ICU in Austria with a COVID-19 diagnosis in 03/2020–03/2021. Exposures: Demographic and clinical characteristics, vital signs and laboratory tests, comorbidities, and management of patients admitted to ICUs were analysed for possible sex differences. Main outcomes and measures: The aim was to define risk scores for mechanical ventilation and mortality for each sex to provide better sex-sensitive management and outcomes in the future. Results: We found balanced accuracies between 55% and 65% to predict the outcomes. Regarding outcome death, we found that the risk score for pre-ICU variables increases with age, renal insufficiency (f: OR 1.7(2), m: 1.9(2)) and decreases with observance as admission cause (f: OR 0.33(5), m: 0.36(5)). Additionally, the risk score for females also includes respiratory insufficiency (OR 2.4(4)) while heart failure for males only (OR 1.5(1)). Conclusions and relevance: Better knowledge of how sex influences COVID-19 outcomes at ICUs will have important implications for the ongoing pandemic’s clinical care and management strategies. Identifying sex-specific features in individuals with COVID-19 and fatal consequences might inform preventive strategies and public health services.

Sexual dimorphism in COVID-19: potential clinical and public health implications

Current evidence suggests that severity and mortality of COVID-19 is higher in men than in women, whereas women might be at increased risk of COVID-19 reinfection and development of long COVID. Differences between sexes have been observed in other infectious diseases and in the response to vaccines. Sex-specific expression patterns of proteins mediating virus binding and entry, and divergent reactions of the immune and endocrine system, in particular the hypothalamic-pituitary-adrenal axis, in response to acute stress might explain the higher severity of COVID-19 in men. In this Personal View, we discuss how sex hormones, comorbidities, and the sex chromosome complement influence these mechanisms in the context of COVID-19. Due to its role in the severity and progression of SARS-CoV-2 infections, we argue that sexual dimorphism has potential implications for disease treatment, public health measures, and follow-up of patients predisposed to the development of long COVID. We suggest that sex differences could be considered in future pandemic surveillance and treatment of patients with COVID-19 to help to achieve better disease stratification and improved outcomes.

COVID-19 and Diabetes Outcomes: Rationale for and Updates from the CORONADO Study

PURPOSE OF REVIEW

In France, in order to describe the phenotypic characteristics of patients with diabetes hospitalized for coronavirus disease-2019 (COVID-19) and to identify the prognostic factors in this specific population, the CORONADO (CORONAvirus and Diabetes Outcomes) study was launched. This review will summarize the key findings from the CORONADO study and put them in perspectives with others studies published on the subject.

RECENT FINDINGS

For almost 2 years, the new SARS-CoV-2 (Severe Acute Respiratory Syndrome-CoronaVirus-2), which causes COVID-19, has spread all around the world leading to a pandemic. From the first epidemiological reports, diabetes mellitus has rapidly emerged as a major risk factor associated with severe forms of COVID-19 but few data were available about diabetes characteristics in hospitalized people with COVID-19. Between March 10 and April 10, 2020, 2951 patients were included in 68 centers throughout the national territory, including overseas territories. In the CORONADO study, the primary outcome was a composite endpoint combining invasive mechanical ventilation (IMV) and/or death within day 7 (D7). Secondary outcomes included death, IMV, intensive care unit (ICU) admission, and hospital discharge, all considered within D7 and day 28 (D28). The primary outcome occurred in 29.0% participants within D7 following hospital admission. Within D28, the end of the follow-up period, the mortality rate was 20.6%, while 50.2% of patients were discharged. In multivariable analysis, advanced age, microvascular complications, treatment with insulin or statin prior to admission, dyspnea on admission, as well as biological markers reflecting the severity of the infection (high levels of transaminases, leukocytes and CRP, and low platelet levels) were associated with an increased risk of death. Several exploratory analyses were performed to clarify the influence of some parameters such as weight status, sex, type of diabetes, and some routine drugs, including metformin or statins.

Determinants of Outcome Among Critically Ill Police Personnel With COVID-19: A Retrospective Observational Study From Andhra Pradesh, India

Background and Aims: Police personnel have been key frontline workers throughout the coronavirus disease 2019 (COVID-19) pandemic. This study was conducted to assess the correlates and outcomes of critically ill police personnel.

Methods: This retrospective observational study analyzed key parameters of hospitalized police personnel who were critically ill with COVID-19 in Andhra Pradesh, India, between June and October 2020. Survival was analyzed for correlation with body mass index, ABO/Rh blood group, co-morbidities, treatment (oxygen therapy, prone positioning, mechanical ventilation, remdesivir, Ivermectin, oral and nasal topical povidone-iodine). We also performed Cox proportional hazard analysis with relevant function plots.

Results: The majority of the 266 patients were male (n = 259; 97.4%) and obese (75.2%). The overall mortality of patients was 38% (n = 101). COVID-19 mortality increased significantly with age (p = 0.019) and BMI (p = 0.030) in the bivariate analysis. There was no significant difference between blood group (p = 0.297), co-morbidity (p = 0.582) and COVID-19 outcome. Multivariable-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of the risk factors for COVID-19 mortality were males (HR 4.89, 95% CI: 1.020-23.430) and ventilator therapy (HR 7.5, 95% CI: 4.527-12.296). The protective factors were symptom onset to reverse transcription polymerase chain reaction (RT-PCR) report interval (HR 0.36, 95% CI: 0.158-0.814), prone positioning (HR 0.43, 95% CI: 0.197-0.915), and use of povidone iodine (HR 0.43; 95% CI: 0.273-0.692).

Conclusion: COVID-19 mortality among critically ill hospitalized police personnel was reduced by time to diagnostic test result, prone positioning, and povidone-iodine use and increased with male gender and mechanical ventilation.

Does diabetes mellitus mitigate the gender gap in COVID-19 mortality?

In this SARS-COV2-pandemic, diabetes mellitus (DM) soon emerged as one of the most prominent risk factors for a severe course of corona virus disease-2019 (COVID-19) and increased mortality due to hyperglycemia/insulin resistance, obesity, inflammation, altered immune status, and cardiovascular complications. In general, men are at a higher risk of severe or fatal COVID-19 disease irrespective of age, region and despite comparable infection rates in both sexes. In COVID-19, there is also a male predominance among hospitalized patients with diabetes, however, overall, data among patients with diabetes are ambiguous so far. Of note, similar to cardiovascular complications, women with type 2 diabetes (DM2) appear to lose their biological female advantage resulting in comparable death rates to those of men. The complex interplay of biological and behavioral factors, which may put men at greater risk of a severe or fatal course of COVID-19, and gender-related psychosocial factors, which may cause disadvantage to women concerning the infection rates, might explain why sex-disaggregated data among infected patients with diabetes are conflicting. Better knowledge on biological factors leading to functionally different immune responses and of gender-sensitive sociocultural determinants of COVID-19 infection rates may help to optimize prevention and management in the high-risk groups of men and women with diabetes.